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#1
13-01-2008, 11:32
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Should heroin be prescribed to heroin misusers? Yes or No?
from the British Medical Journal:
[top]Should heroin be prescribed to heroin misusers? Yeshttp://www.bmj.com/cgi/content/short/336/7635/70 Jürgen Rehm, chair1, Benedikt Fischer, professor1,2 1 Centre for Addiction and Mental Health, Toronto, ON M5S 2S1, Canada, 2 Centre for Addictions Research of British Columbia, University of Victoria, Canada Correspondence to: J Rehm jtrehm@aol.com doi: 10.1136/bmj.39422.503241.ADdoi: 10.1136/bmj.39434.460694.AD Some heroin addicts are very difficult to treat. Jürgen Rehm and Benedikt Fischer believe that maintenance with heroin is the way forward for this group, but Neil McKeganey argues that it is treating the effects of misuse not the addiction Recently, a public hearing of a Danish parliament subcommittee discussed whether heroin assisted maintenance treatment should be offered experimentally to reduce health and social harm related to use of heroin (www.tekno.dk/ordineret-heroin). This is just one in a series of similar—existing or proposed—programmes in Europe, North America, and Australia.1 We believe that such treatment is appropriate for heroin misusers under certain circumstances. [top]Supporting evidenceIncreasing heroin misuse in the United States in the early 1970s led to a public debate about prescribing heroin as a last resort form of opioid maintenance therapy for people with chronic heroin dependence. In 1973 Lorrin Koran advocated in the New England Journal of Medicine that "carefully designed clinical research on the safety and efficacy of heroin maintenance should be undertaken, particularly with addicts not helped in current treatments."2 Some 35 years later, three important research studies have been completed. In Switzerland, a small randomised trial3 and a study using natural cohort designs4 found heroin assisted maintenance treatment to be feasible and effective for a group of heroin misusers who were refractory to treatment, as characterised by long term heroin dependence; physical, psychological, or social deficits; and unsuccessful previous treatment.4 5 Effectiveness was observed in treatment retention; somatic health outcomes such as epileptic episodes, abscesses, or cachexia; mental health outcomes such as affective or anxiety disorders; heroin and cocaine misuse; and criminal outcomes such as property offences or drug trafficking (on the basis of self report and objective measures).5 Large randomised controlled clinical trials in the Netherlands and Germany, which compared different modes of heroin assisted maintenance treatment with methadone maintenance treatment, obtained positive results on similar outcomes.6 7 Moreover, heroin assisted maintenance treatment was found to be cost beneficial in Switzerland8 and cost effective in the Netherlands compared with methadone maintenance treatment.9 Since these results were obtained, this treatment option has been extended beyond the trial periods, and heroin has been approved by the regulatory bodies for treating opioid dependence. In all three countries, the intake of medical heroin is supervised and occurs a maximum of three times a day, and patients recover from acute intoxication before leaving the treatment clinic. Notably, heroin has been a treatment option for heroin misusers in the United Kingdom for several decades, albeit on a relatively small scale and under different conditions—with lower average dosing and less supervised intake.10 [top]Use of maintenanceThe above summary makes the recent use of heroin assisted maintenance treatment look like a straightforward scientific success story, and not like a topic for debate in the BMJ. However, since the original heroin assisted maintenance treatment programme was proposed in Switzerland in the early 1990s, there has been scientific, and perhaps more importantly, larger public debate on the ethics, safety, and clinical value of prescribing heroin, and to a lesser degree, on maintenance treatment in general. Overall, maintenance with buprenorphine and, to a larger degree, methadone is more successful than treatment focusing on abstinence or using placebos.11 Given the nature of opioid dependence as a chronic relapsing disease,12 these results are not surprising. 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? One reason that has been cited is safety, both for the patient13 and for the general public (for example, through diversion or the risk of trivialising the dangers of heroin, leading to an increase in use). Results from the Swiss studies, however, show that mortality among patients in heroin assisted maintenance programmes is low, and lower than for patients in other maintenance programmes.14 In addition, the wider safety concerns could not be empirically confirmed in Switzerland or the Netherlands.15 Finally, the incidence of heroin dependence has decreased greatly in Switzerland since the start of the trials, and currently heroin has a more negative image than it did 15 years ago.16 Overall, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence. However, the development of an overall integrated treatment system is crucial. All studies to date have been conducted in samples of refractory addicts with severely compromised health and several previous failed attempts of methadone maintenance treatment. Our current knowledge about the effectiveness of heroin assisted maintenance treatment is restricted to these groups and to the context of countries where there is already an established and effective comprehensive system for treating opioid dependence. Although we currently do not have the necessary empirical evidence for establishing heroin assisted maintenance treatment in other circumstances, addition of heroin assisted maintenance treatment would be likely to improve the overall treatment system, especially with respect to so called treatment resistant and refractory opioid addicts. doi: 10.1136/bmj.39422.503241.ADdoi: 10.1136/bmj.39434.460694.AD Competing interests: None declared. [top]References
[top] Should heroin be prescribed to heroin misusers? Nohttp://www.bmj.com/cgi/content/short/336/7635/71 Neil McKeganey, professor of drug misuse research 1 University of Glasgow, Glasgow G11 6PW n.mckeganey@lbss.gla.ac.uk doi: 10.1136/bmj.39421.593692.94doi: 10.1136/bmj.39434.460694.AD Some heroin addicts are very difficult to treat. Jürgen Rehm and Benedikt Fischer believe that maintenance with heroin is the way forward for this group, but Neil McKeganey argues that it is treating the effects of misuse not the addiction Prescribing heroin to heroin addicts is a strategy beloved by top police officers1 and successive home secretaries.2 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?" The evidence in relation to heroin prescribing is far from conclusive. On the positive side Nordt and Stohler have suggested that heroin prescribing led to a large reduction in incidence of heroin addiction in Switzerland, although the authors also point out that such prescribing may have reduced individual’s inclinations to cease their heroin use.3 A London study found no health benefits associated with heroin prescribing,4 whereas various Dutch and Swiss heroin trials have identified a range of benefits including improved social functioning and psychological and physical health.5 6 What is often quite difficult to identify from these studies is the degree to which the improved outcomes are the result of the heroin prescribed or other elements of the therapeutic programme provided. The cost of treating an addict with heroin is estimated to be three to four times that of treating an addict with methadone.7 [top]Risks of prescribingIn the face of the additional costs and inconclusive evidence, many clinicians are wary of prescribing heroin. Their anxieties are understandable, given the high profile cases of doctors who have prescribed heroin to addicts and then subsequently found themselves facing a General Medical Council inquiry into their prescribing practices.8 At a clinical level prescribing heroin to heroin addicts is a risky strategy. Once you start, it is difficult not to feel that you have ceded authority for your prescribing to your patient. What, for example, do you say to patients who threaten to resume their previous life of crime if you reduce their heroin prescription? What do you say to the cocaine addict who asks why he cannot have cocaine provided in the same way as the heroin addict? Opening up heroin prescribing to addicts could lead to massive pressure on doctors to prescribe increasing amounts of the drug. It was in part as a result of that pressure that the Interdepartmental Committee on Drug Addiction advised the UK government in 1965 that only appropriately certified doctors should prescribe heroin to addicts. The committee’s decision was influenced by the case of Lady Frankau, a noted London psychiatrist who in 1962 prescribed more than 600 000 heroin tablets to her addict patients.9 [top]What are we treating?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. Research has shown that with the right services in place it is possible to do more than simply stabilise addicts’ continued drug use through the prescribing route. For example, the Australian treatment outcome study, which followed up 429 heroin users recruited from a random sample of drug treatment agencies 36 months after starting treatment, found that 40% of drug users had been abstinent for the preceding 12 months and 25% had been abstinent for the preceding 24 months.10 In a similar Scottish study of 695 addicts, re-interviewed 33 months after they had started treatment for drug misuse, 29.4% of those who had been provided with residential rehabilitation had been abstinent for at least 90 days before being interviewed compared with only 3.4% of those receiving methadone maintenance.11 All of the residential rehabilitation services included in this study followed an abstinence based programme. 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.12 Most of those questioned said that they wanted the services to help them become drug free. Health services need to ensure that they are supporting addicts’ attempts to become drug free, and they need to be extremely cautious about any extension of a policy that could be seen as a route to maintaining rather than reducing an individual’s drug dependency. doi: 10.1136/bmj.39421.593692.94doi: 10.1136/bmj.39434.460694.AD Competing interests: None declared, [top]References
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#2
14-01-2008, 00:17
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
swims conclusion is that diacetylmorphine (heroin) maintenance treatment should be an option. actually it should be more than an option, it should replace methadone and buprenorphine maintenance. methadone addiction is worse in a lot of addicts eyes and is way harder to get off. even buprenorphine can be harder to get off. swim is on it (suboxone) and would rather suffer the old heroin withdrawals any day, mainly because they are so short in duration.
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#4
14-01-2008, 02:44
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
I think decisions like this should be up to a trained professional doctor. Not that people aren't capable of making a good decision (some, if not most are) but i really believe to just give an addict an option to have more of a drug isn't always the way to cure an addiction.
Just a show of hands has anyone had an effective rehab with this method. I am not very knowledgeable and if anyone has i would love to hear of its effectiveness.
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#5
16-01-2008, 01:05
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
SWIM has known far too many fucking junkies in his lifetime and in his opinion heroin should absolutely be prescribed. Other options should be encouraged, but if junkies were able to get thier shit from a medical professional, know the exact dosage, and get shot up in a sterile environment by a doctor or nurse there would be far fewer overdoses, they wouldn't have to go to dangerous neighborhoods to get thier shit, and they wouldn't be supporting organized crime with thier purchases. Addiction is absolutley tragic and ruins the beauty of opiates but it could be less awful if more progressive policies were enacted.
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#7
18-01-2008, 03:15
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
I'm sorry but SWIM thinks that not all the comments in this thread appear to be entirely well informed.
He mantains that for those who can read danish (admidedtly not the most useful language in the world) the Folketing (danish parlament)'s report is quite to the point , even if as usually the conclusions it comes to are woefully inappropriate and ultimately useless. Coconut can surely give us better advice on subjects he knows better (or even better those he had personal experience of). SWIM explained to me that the first thing to keep in mind, specially when talking about opiates, is the difference between dependence and tolerance. All opiates are addictive (that is induce dependence). But the time in which the body develops a tolerance to the different compounds is very different. Very fast for dyacetylmorph, slower for methadone, even slower for buprenorphine. This means that a subject assuming dyacetylmorph will soon be tollerant to the molecule; i.e. that to obtain an effect equivalent to that of the original dose, within a very short time he will need to either increase the doses or decrease the time between them. This "tolerance phenomenon" is markedly less accentuated when the substance assumed is methadone or buprenorph. Swim knows what he is talking about. He tried himself to detox with decreasing doses of H, and not just one or two times. Sorry pals. He's sure that it just can't be done. You're more likely to meet Santa Claus than some fella who actually detoxed using Heroin. Swim tried more than once with opium too. He lovingly prepared his different "pills" of decreasing weight and concentration , studied a detailed plan, took off to some tropical island and invariabily failed miserably. He's convinced that it can't be done. He says that there is no point in trying to fix your tyres with chewing gum. It may seem a good idea but it just does'nt work. The inevitable developement of tolerance symptoms is the reason why is basically impossible to mantain a constant dose of dyacetylmorphine over a prolonged space of time. The dose that will take a user to nirvana in the beginning will just make him feel OK after a while ; and after some more time will not even do that anymore. The reason for the different tolerance levels caused by these closely related molecules is what pharmacologists call their "Half Life". Basically this is the lenght of time in which the concentration of a molecule will decrease by 50% its presence (and action) on the nervous system. Heroin's (or opium's) half life is shorter than that of methadone which in turn is shorter than that of buprenorphine. The two latter molecules then will produce far less tolerance (allowing the dose/time ratio to stay constant over long periods of time) but far stronger addiction (dependence is actually a more correct term). The strongest addiction is of course produced by assumption of the molecule with the longest "half life". Therefore is very important that buprenorphine be always assumed in decreasing doses and NEVER EVER for more than four consecutive weeks. From what Swim has learned in this forum, the posology with which buprenorphine gets prescribed in the USA is nothing less than criminal. JaWill88 is absolutely right to say that he would rather have back back his old Heroin addiction in exchange for the one to suboxone. The point is that no doctor should ever have allowed dependence to suboxone to arise in first place. Buprenorphine maintenance therapy is madness. JaWill88's doc should put him back on dyacetylmorph for eight to ten weeks and then start a serious detox program with decreasing doses of methadone. As far as SWIM knows, no med school in the world teaches opiate detoxing to their students. This means that unless the doc is regularly and specifically adjourned on the subject, your pusher is likely to be better informed than your doc about it. Dyacetylmorphine should be legally prescribed for a wide range of therapies (including detoxing from wrongly done detoxing with buprenorph. &methadone); but , let's not kid ourselves: If the goal is to get rid of opiate addiction then It's never been and it will never be the right substance to employ. At the cost of sounding cynical, SWIM's mantains that he would suggest to all those fellow travellers who have been on buprenorphine or methadone for more than 5/6 months, to get back to heroin for a few weeks and then start to detox in the appropriate way. He also said that if one of them would decide to shoot his doc on his kneecaps, he would have all his approval an support. VV Last edited by VincentVan; 18-01-2008 at 09:58.
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#8
06-02-2008, 15:10
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
I just got home from an inpatient detox and I absolutely think that heroin should be prescribed to 'misusers'. Everybody else has already pointed out why, but there are far too many advantages to the treatment to reasonably deny it to opiate tolerant users.
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#9
07-02-2008, 06:47
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
If it keeps the "misusers" from stealing my fucking car radio, well that's all the reason I need to say "yes."
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#10
07-02-2008, 07:34
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
yes herion maintenance is proven more effective than methadone or bupe
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#11
07-02-2008, 11:00
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Quote:
LOL!!! sorry as swim finds this hilarious, as in oh so true. what swim means is he got soooooo damn sick of his stupid fucking suboxone (buprenorphine) and it's rediculously long withdrawals (yes, even long than methadone's) that he just bought a half ounce of diacetymorphine (black tar of course, swim couldn't even imagine what a half ounce of relatively good powder herion would cost, and no he isn't asking for prices). swim only assumes it is much more as all the black tar around swim has done he has had to do at least .2 of gram to stay straight but at one VERY SICKENING point in time, 1 gram per shot to stay straight. that was a ball (3 grams, thats what it is with heroin unlike cocaine and stuff which is 3.5) a day. from what swim has heard it takes WAY less powder heroin. and swim gets pretty damn decent tar. swim has gotten tar from soooo many different dealers and what he is getting now is some of the best he has had and has been going through these people for at least a year and a half. they sell coke and heroin and never buy under 2 kilos of each when the re up and they DO NOT cut it themselves at all. swim is just trying to say he knows he gets good tar and it still probably takes way, way more of that than good powder. well right now swim is forcing himself to do .2 grams 3x a day (.6 grams per day), of course sometimes he would like to do more but doesn't really care that much. all he cares about is getting off this stupid medicine. well swim bought a digital scale and weighed out all .2 shots and it came out to exactly how much it should have. 12 grams ( a half ounce in heroin terms) would last 20 days and when swim did all the dividing it came out to exactly that, so swim was quite pleased. but as swiy said, maybe 8 to 10 weeks? swim has been seriously wondering how long he needs to stay on so there will be no buprenorphine withdrawals as he may actually detox using it (only for like the worst 3, maybe 4 days.) swim was sure it would be at least a month. swim figured around a month and a half. but swim is thinking of going two and a half months just to be sure. the last thing swim wants is to do all this heroin and experience buprenorphine withdrawals  lol. god that would just be aweful. swim cringes when he thinks about that. swim has been on suboxone for a bit more than a year now (got on the day after christmas 2007 and has almost always been on the highest dose possible which is 32mg a day. swim would take 16mg twice a day. well swim REFUSUES 100% to have to take some stupid ass orange pill every day that does nothing, yet if he doesn't take it, swim goes through HELL. the withdrawals are sooooo damn long it really is sickening. as swiy said above it really is basically criminal. it should be outlawed. swim hasn't met one person who got off of it successfully, regardless wether the taper was 21 days or 2 years. it just fucking rediculous. swim tried numerous times and never made it past day 16, which is when the withdrawals were just starting to become their worst. to suffer like that should be illegal lol. anyways swim is just glad to hear someone else has something INTELLIGENT to say about all of this. btw, should swim do heroin for 2.5 months before trying to come off? this is really the big question for swim, the one swim can't find a straight answer to, the one that matters ohhh so much, more than anything else. swim would love to hear some more input/confirmation. thanks. btw, to peoples who have opioid problems, these long acting meds absolutely ARE NOT the answer. it doesn't matter how bad ones habit is, it just isn't the right way. swim can say without a doubt that this was THE BIGGEST MISTAKE he ever made in his life, getting on buprenorphine. the only way it is any good is if one really wants to stay on this shit till they die. and also swim must add, swim knows buprenorphine is supposed to be sooo much weaker and milder than methadone and what not, but swim has met numerous people who had a WAY harder time coming off buprenorphine than methadone. and all of those people were on doses of methadone equivelant to higher than their buprenorphine and were all on methadone at least twice as long as they were on buprenorphine. swim is definately not saying thats going to happen to everyone, but it definately happens to some people. just trying to warn people. anyways good luck to the opioid dependants out there. swim for once is nodding off! lol swim hasn't felt that in a while and is going to enjoy it while it's there. this is swims third day using heroin so these nice extra effects probably won't last long, so peace.
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#12
07-02-2008, 11:44
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Look into ibogaine, brother. I can't even imagine the life SWIY is leading.
Wow. Banging black tar to detox from bup, suboxone, and/or methadone; what a fucked-up situation. SWIY has all my respect just for making it through one more day...
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#13
07-02-2008, 12:14
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Heroin is prescibed to 0.5% of addicts in the UK, by special licensed doctors when the patient has failed numerous methadone programs.
http://www.drugs-forum.com/forum/sho...ght=heroin+nhs See this interesting thread I posted about one womans story, and her daily heroin prescription.
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#14
07-02-2008, 19:46
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
nobody addicted to Herion ever feels(right) after years of abuse, use. give the people what they want , tax the govt. for the program. register addicts, and watch the crime rate go down,
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#15
07-02-2008, 20:37
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Quote:
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#16
08-02-2008, 11:00
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
in swims post above he said he had been on suboxone (buprenorphine) for more than 1 year and at the highest dosage for almost all the time he'd been on it. in a nutshell swim would rather suffer heroin withdrawals any day of the week than suboxone withdrawals because heroin withdrawals never seem to last more than 7 days and suboxone withdrawals (at least for swim) seem to last like 2 months. they aren't quite as intense but still pretty close so it's obvious one would rather suffer the 7 days, well unless that person is addicted pain or something lol. anyways swim is using heroin to get off suboxone and has been doing that for like 5 days now. in his above post he asked how long swim needs to do heroin before detoxing and the detoxing will be heroin withdrawals and definately not suboxone withdrawals. above one swiy said maybe 8 - 10 weeks. that sounds about right to swim. swim has a theory (which is based on absolutely nothing) that swim needs to do the heroin at least as long as the suboxone withdrawals would last. but that's just his theory. it also could be just until swim is physically addicted to heroin, which these days for swim it seems all he has to do it for is anywhere from 3 - 7 days with 3 shots a day. when swim started doing it he definately had to do it 3 times a day and it would take a good couple weeks to go into withdrawal but it seems to not be that way anymore. but swim doesn't think this second theory is the correct one, most likely the first one. but to get to the point, is there anyone who has any knowledge on this? maybe just an opinion? some kind of feedback? that would be awesome as this is something swim needs to figure out pretty soon as he is back on heroin now and doesn't really want to do it longer than necessary but would rather do it for too long than not long enough and end up suffering buprenorphine withdrawals. swim realizes this is kind of off topic but was being discussed earlier, but if it's a problem someone could gladly put and end to this and swim could start a new thread. thanks.
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#17
08-02-2008, 13:05
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Quote:
http://www.nta.nhs.uk/publications/d...03_summary.pdf Just thought I'd add another thread on this topic that may be of interest. http://www.drugs-forum.com/forum/sho...ght=heroin+nhs
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#18
11-02-2008, 01:49
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
YES YES YES, Please! If swim was prescribed H, then swim would be able to live a normal life, no more spending most of his life finding cash. Swim would be a perfect case for this as he's been taking methadone on & off for ten years, in two different countries. (England & Spain) Even previously taking 270ml daily in Spain and currently taking 100ml daily in UK. Methadone gives swim a withdraw for months on end, horrible. Although its not much better withdrawing from street H, just weeks rather than months. How in 2008 we don't have good treatment, cure or many choices for addicts, crazy in my opinion.
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#19
11-02-2008, 12:08
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Quote:
It does seem sensible but would cost the NHS alot more than methadone maintenance. It would probably cause uproar within the non-drug using, tax paying community. Something along the lines of (why are my hard earned taxes going to pay for those druggies heroin!?). I think it is very much a political thing. The withdrawals from methadone are terrible I agree, but I think diamorphine should only be prescribed to addicts that have failed multiple methadone programs over a number of years and have relapsed time and time again.
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#20
11-02-2008, 18:59
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Well ''Rocksmokinmachine'' I agree with ya on that about what every one else would say about it, and maybe it would of been a good idea for swim considering all the methadone courses he's been on. Today been thinking about it and really swim wants to get away from H, to be prescribed it would mean the rest of his life on it.
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#21
12-02-2008, 14:46
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
It is used in the UK, currently 0.5% of addicts in treatment have a diamorphine prescription.
Buprenorphine is by far the best medication available for heroin addiction SWIM says, methadone just exasperates the situation and engourages the addict to "top up". Most of the addicts SWIM knew provided positive urine samples for both opiates and methadone on a regular basis. On a plus side it was something to "fall back on". But that was it.
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#22
15-06-2008, 20:54
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Quote:
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#23
29-08-2008, 23:58
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
yes.
definitely. i want my share 
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#24
04-09-2008, 13:24
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
Sorry to dig up an old thread,but the question is an absolute no brainer......of course diamorphine maintenance works.
Hell,it worked for me for years.
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#25
04-09-2008, 14:12
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Re: Should heroin be prescribed to heroin misusers? Yes or No?
SWIM thinks heroin should be prescribed to addicts as a means of providing stability in their lives.
After taking prescribed heroin for some time they could then make the step to switching over to orally ingesting opiates (methadone ect.) After staying on oral opiates for some time the posibility of giving up opiates completely could then be considered.
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