Heroin-assisted treatment improves patients' health along with their quality of life

by Julie Nybakk Kvaal, University of Oslo

edited by Lisa Lock, reviewed by Andrew Zinin

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At two clinics in Oslo and Bergen, a small group of patients have been given a new treatment option for opioid addiction. Twice daily, they receive pharmaceutical heroin as medication, administered under close supervision and monitoring by health personnel.

"With heroin-assisted treatment, patients receive medical heroin within a structured, interdisciplinary setting," says Desiree Eide, researcher at the Norwegian Center for Addiction Research (SERAF) at the University of Oslo.

The treatment was offered to people with severe heroin addiction who had previously undergone addiction treatment without sufficient effect. The standard treatment is opioid agonist treatment (OAT), called "LAR" in Norway, in which drugs such as methadone or buprenorphine are administered as a substitute for heroin.

"HAT is an offer for a small, highly burdened and vulnerable group, for whom ordinary OAT has not been sufficiently beneficial. HAT is typically not the first choice," Eide says.

In addition to medication, patients receive medical follow-up and support for psychological problems, drug use and social challenges such as housing, finances and social networks. The aim is to improve the health of the patients and create more stability in their everyday lives, while also reducing fatal overdoses.

HAT is more than medication

HAT was initiated as a national pilot by the Norwegian Directorate of Health, and now, after four years, the project has been evaluated. The published evaluation report concluded that it is not just the heroin medication itself that has an effect, but the whole treatment framework around it.

"Both patients and staff describe the treatment as 'more than a medicine.' They point out that the close, intensive monitoring is an important part of what works," Eide says.

Several patients describe the treatment as lifesaving. They say that HAT has meant a lot to them and that it has changed their lives for the better.

"We have not been able to measure mortality directly in this project, as there have been too few patients involved for such calculations to be adequate," says Thomas Clausen, professor at SERAF.

He nevertheless emphasizes that patients who enter and stabilize in drug treatment have a lower risk of dying from overdoses, partly because they use fewer narcotics.

"Many people feel that this treatment has meant a lot and changed their lives positively. Those who offer the treatment have received good feedback. We also see that many people experience measurable positive effects from the treatment," Clausen says.

HAT has provided a gradual improvement in health and quality of life

The people who start HAT have complex problems. They have a severe, long-term substance use disorder and have problems with both their physical and mental health. Many of them are socially marginalized, have an unstable housing situation and have been unemployed for a long time.

"Among the most important things we see is how the treatment leads to a moderate and gradual improvement in the health and quality of life for most people," Clausen says.

At the same time, the picture is nuanced. "Some say their 'life has been turned around," they have begun working, and describe their everyday life as completely changed. Others report more subtle changes, but still experience improvements after being in HAT," he says.

The evaluation also shows that the patients use less illegal heroin while they are in treatment, and they also report less crime over time.

Not a lifelong solution, but a transition

HAT is not necessarily a permanent treatment for everyone. For many people, the offer functions as a transition to ordinary treatment.

As many as 88% of the patients who were discharged as planned went on to receive ordinary OAT.

"This suggests that HAT both stabilizes patients and that it can act as a bridge to less intensive treatment," Clausen says.

HAT reaches the target group, but it is expensive

The HAT model, however promising, requires a lot of resources. The clinics retain a high level of staffing to provide close monitoring throughout the treatment and to handle the patients safely.

Nonfatal overdoses were relatively common during the project period. Although these are serious incidents, it shows that the treatment is reaching some of the most vulnerable patients. It also suggests that overdoses are detected and managed within a controlled treatment environment, rather than occurring outside it, where the outcome can often be more serious.

The treatment is also expensive, with a high cost per patient.

"Based on the evaluation, we do not recommend that the offer be expanded nationally. We consider it too expensive. We still believe that HAT is a relevant offer that should be continued in the two cities where it has already been established, and where, most likely, the most patients in need of this type of treatment reside," Clausen says.

What happens next with heroin-assisted treatment?

The project was controversial when it began. The Norwegian Directorate of Health therefore commissioned SERAF to conduct a broad evaluation, using multiple methods and giving clear recommendations for the way forward. The researchers have closely followed HAT throughout the entire period, from its inception to the present.

"It is important that new treatment measures are thoroughly evaluated, so that we can learn more about what works and what doesn't. Then the course can be adjusted if it is necessary," Clausen says.

For the researchers, the discussion is now not about whether the treatment is effective, but to what extent it should be implemented in Norway.

"We know that HAT helps patients, but how it should be implemented moving forward is a political question," Eide says.

"The evaluation shows that HAT can be a beneficial and intensive alternative for a small group of people. But the future of the offer depends on how it is organized, how it is integrated with other services, and how it is weighed against the wider needs in drug treatment," she says.

More information

Report: Evaluation of heroin-assisted treatment in Norway

Key medical concepts

Opioid addictionQuality of LifeMethadone

Clinical categories

PsychiatryPsychology & Mental health Provided by University of Oslo Who's behind this story?

Lisa Lock

BA art history, MA material culture. Former museum editor, paramedic, and transplant coordinator. Editing for Science X since 2021. Full profile →

Andrew Zinin

Master's in physics with research experience. Long-time science news enthusiast. Plays key role in Science X's editorial success. Full profile →

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