[Heroin Prescription and History. Virginia Berridge, Ph.D. N Engl J Med 2009;361;8 august 20]
In this issue of the Journal, Oviedo-Joekes et al. report on the results of the North American Opiate Medication Initiative (NAOMI) trial comparing methadone with injectable diacetylmorphine (the active ingredient in heroin) for the treatment of heroin addiction. These data from North America point to a conclusion that has been widely supported, although not without controversy, by similar recent studies in Europe.2 The results of this trial may be added to those from Germany, the Netherlands, Spain, and Switzerland. Switzerland has 10 years of experience in the prescription of heroin, and in a November 2008 referendum, 68% of voters were in favor of its continued prescription.
The prescription of heroin is rigidly controlled, and some commentators have asked whether a less restrictive and more clinical approach might make a difference to the proportion of drug users who are treated with heroin.3 Guidance on the prescription of heroin published by Britain’s National Treatment Agency for Substance Misuse in 2003 stressed that the drug should be prescribed as a last resort and under the medical control of a specialist. The prescription of heroin is now recognized in some European countries as the optimal treatment for patients for whom options are running out and in whom methadone maintenance has not worked, and it keeps the user in contact with drug services.
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