"The present study determined participants’ satisfaction with received treatments in the first North American RCT [Randomized Controlled Trial] to provide injectable diacetylmorphine or hydromorphone compared to oral methadone for the treatment of long-term, treatment resistant, opioiddependency. At 3 and 12 months, participants were satisfied with the treatment received during the study period, although satisfaction was greater for those randomized to receive injectable treatments.

"Our results on the cost-effectiveness of diacetylmorphine are consistent with those of an economic analysis based on data from two Dutch heroin-assisted treatment trials,²¹ despite differences in the design of the Dutch trials and the North American Opiate Medication Initiative, and the time horizon and analytic design of the economic analyses.

"Over the past 15 years, six RCTs [Randomized Controlled Trials] have been conducted involving more than 1,500 patients, and they provide strong evidence, both individually and collectively, in support of the efficacy of treatment with fully supervised self-administered injectable heroin, when compared with oral MMT, for long-term refractory heroin-dependent individuals.

CONCLUSIONS
"1. Heroin-assisted therapy proved to be a safe and highly effective treatment for people with chronic, treatment-refractory heroin addiction. Marked improvements were observed including decreased use of illicit “street” heroin, decreased criminal activity, decreased money spent on drugs, and improved physical and psychological health.

"The NAOMI study provided injectable HDM to a small group of participants. An unexpected finding was that many participants couldn’t tell the difference between the effects of diacetylmorphine and HDM.

"However, the small number of participants receiving HDM did not permit researchers to draw any definite and scientifically valid conclusions as to the efficacy of HDM as a treatment option.

"Therefore, the SALOME investigators designed a study to test this hypothesis.

"The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) is a clinical study that tests alternative treatments for people with chronic heroin addiction who are not benefiting sufficiently from available treatments such as oral methadone.

"SALOME compared two medications – diacetylmorphine, the active ingredient of heroin, and hydromorphone (HDM), a legal, licensed pain medication.

"Based on its 1992 call for proposals, the Federal Office of Public Health authorized HAT trials in Zürich, Bern, Basel, and Geneva involving about 1,000 persons in the first instance (Bammer et al. 2003). Studies of HAT continued in Switzerland beyond the first trials. The full results of this work are beyond the scope of this paper, but what may be hundreds of peer-reviewed journal articles on the trials, as well as a book produced by FOPH (Rihs-Middel et al.

"A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.

"Heroin prescription is a form of medical care that involves strictly regulated and controlled prescription of heroin. Offered on its own or as a complement to treatment programs, it is often targeted for use by people for whom opioid substitution treatment and other programs have not succeeded."

"Findings show such programs are feasible and are associated with a number of positive outcomes,¹² including:

"Heroin misuse in Switzerland was characterised by a substantial decline in heroin incidence and by heroin users entering substitution treatment after a short time, but with a low cessation rate. There are different explanations for the sharp decline in incidence of problematic heroin use. According to Ditton and Frischer, such a steep decline in incidence of heroin use is caused by the quick slow down of the number of non-using friends who are prepared to become users in friendship chains.