Running head: PHASE III PAPER Randomized Trial Of Herion Maintenance Program

Randomized Trial of Heroin Maintenance Program for Addicts who Fail Conventional Drug
Judith Brusseau
SW 3810
April 15, 2014

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Randomized Trial of Heroin Maintenance Program for Addicts who Fail Conventional Drug
Introduction
There is a story that is written online in by By Michael A. Fuoco who is a writer for the
Pittsburgh Post-Gazette. It is called A Heroin Addict Tells Her Story (2012). The story talks
about the grip that heroin can have on a person, even after only using it once. Just one use and
you are hooked. This story begins with a 24-year-old heroin addict. She had been chasing a
never to be found again high for many years. Unfortunately, it took a very long time for her to
realize that she was chasing a high that is non-existent. By doing so, the drug caused the young
woman to become so hooked that her body and mind needed to have it in her system or she
would become dope sick. Dope sickness occurs when an addicts needs a drug, such as heroin, to
maintain a feeling of being normal. In other words, she did not obtain the drug to get high
anymore; she needed the drug to function. Heroin had now become her ball and chain. (Fuoco,
2012)
Fuoco goes on to talk about how her story begins like a lot of those who become addicts.
When the young lady first started into drugs, marijuana was her 1st choice. Marijuana use
quickly worked its way up the drug ladder and she found herself using heroin. Her addiction
became so bad that she had resorted to stealing, even from her own family, to get the drug. In
the story, she mentions that it became a full time job to obtain money so that she could buy more
of the drug. Why? So that she could feel normal, so that her day would be functional. If she
didnt use heroin, withdraws came pretty fast and furious. Nausea, vomiting, diarrhea, hot and
cold chills, sweating and muscle aches occurred often as the drugs moved out of her system. The
withdrawals also affected her mentally, which also made her a slave to anxiety, depression and
insomnia. She would spend her entire day chasing the drug. In order to do so, she created

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repetitive cycle of stealing, looking for a hook-up and using the drug. (Fuoco, 2012) This
terrible consequence of using heroin had become a full-time job. All of these actions were
performed so she could feel normal.
The story concludes with her mentioning how she had lost most of the people that she
cared about, including friends and family because of her addiction. Heroin was the only thing
that stuck by her. The young lady had been in rehab three different times and each time, she
was unsuccessful. (Fuoco, 2012) The power of the drug will trap you, suck you in and then it
will not let go. This story raises the question of what can an addict do when all of his/her
options to quit using have been utilized? What can they do next to live a drug free life?
I have personally never been in the presence of heroin. I do not know what it looks like
and I do not want to know. The reason why I find heroin addiction so interesting is because
addiction runs in my family and in my childrens fathers family. Although the addictions are
mostly with alcohol, it still frightens me. Now that my children are teenagers, I grow
increasingly concerned about the possibly of them developing an addiction as they grow older.
Are they going to become addicts?
Statement of Problem
Heroin use is a social problem because it does not only affect the user. It can also affect
those around them, even the community. It is linked to an increase in crime, which can involve
manufacturing the drug, possessing it and selling it. Addicts also resort to theft and violence to
get their fix. This includes the use of weapons, various levels of violence and even terrorism.
Heroin also leads to users causing problems that they otherwise would not think of doing. Aside
from health issues and the physical problems that come from heroin use, addicts they involve

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themselves in risky behavior that can lead to STDs and physical abuse. Lastly, heroin affects
relationships and families, too.
Over the years there have been many types of drug treatments that have been used to help
addicts quit the habit. Medication therapy is one that is widely used for treatment. These drugs
include Buprenorphine, Methadone, Clonidine, Lofexidine, Naltrexone and Naloxone. (The
Detox Center (n.d.) The drugs are primarily used to help the addicted individual deal with the
cravings and withdrawal and have been approved by the Food and Drug Administration. (The
Detox Center, n.d.) Unfortunately, not all users were able to use these drugs effectively because
they were completely powerless over heroin.
In Switzerland, researchers decided to try to alleviate some of the issues involving heroin,
its effects on the community as well as the effects on the users. (Perneger, Giner, Rio and Mino,
1998) To do so, they decided to devise a study where an addict can be treated with heroin
instead of other conventional drugs to see if there were any remarkable changes that would have
a positive effect on the community and the user. (Lynne, 2008) The purpose of the study was
not to stop heroin usage, but to study its use and how it affects the community and the users
themselves. (Lynne, 2008) This controversial study came out in Switzerland, Geneva to be
exact. It began in 1998 and today is considered to be a randomized trial because it consists of a
design where participants are assigned into one of two groups, an experimental group, which in
our case is a group of participants who received intravenous heroin injections and some
psychosocial services and a control group, which in this case included patients who used other
conventional drug treatment, methadone maintenance as the most popular. (Perneger, 1998)
The outcome variables of this study involve the differences between both of these groups and its
outcome at the close of the experiment. (Perneger, 1998)

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The intervention was considered to be controversial because instead of using prescribed

medications to the experimental group, heroin was used. (Lynne, 2008) It was conducted in
Geneva, Switzerland in 1998 and their government decided to allow for a randomized trial,
which would recruit heroine addicts. They were recruited from drug treatment centers and were
then screened by a psychiatrist. Those eligible were then advised about the program, assessed
and asked to sign an informed consent. After that, the potential patient would be picked through
a computer generated random number that was in a sealed envelope. *** Once recruited,
scientists would eventually measure the outcome of the experimental group of participants who
were treated with heroin. They were looking for changes in the use of the drug, check their
health status and also their social functioning at the end of the trial period. (Lynne, 2008) They
would also check the sample group for the same things and make a comparison and note any
differences between the two groups. This experimental program is known as The Randomized
Trial of Heroin Maintenance Program for Addicts Who Fail in Conventional Treatment
Programs. (Perneger, 1998)
Research Design
This study appears to have the characteristics of being a randomized trial because the
participants were divided into two groups. (Musto, Korsmeyer & Maulucci, 2002) The first
group consisted of users getting injections of heroin and the second group was getting injected
with drugs other than heroin, in most cases, Methadone. (Musto, Korsmeyer & Maulucci, 2002)
Because of these factors, we can also determine this study to be experimental, too. The study is
also considered a blind study because the participants are unaware as to whether they are in the
experimental or control group during the trial period. (Perneger, 1998) It is also a controlled
study because researches are able to determine which participant received heroin and which

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participant used methadone or another type of drug to reduce the urge to use. (Perneger, 1998)
The groups in this trial had to follow certain criteria to get involved. This included
characteristics of failure of success in other treatment programs, daily consumption of heroin and
poor health along with poor social conditions. (Ali, 1999) The threats to internal validity of the
trial included questions concerning the size of the population of the trial. (Lynne, 2008) The
sample and control groups were relatively smaller and that raised a question of the validness of
the study. (Lynne, 2008) Another threat concerning the internal validity included the idea of
distributing heroin to addicts. (Lynne, 2008) It was thought that doing so may be detrimental to
the participant, seeing that they are addicted to the drug and it could possibility increase the
chance of causing further addiction. (Lynne, 2008) Finally, a question was raised in reference
to the trial and it being overall helpful to users if it contributed to the legality of heroin. (Lynne,
2008) These points confirm that a number of threats had occurred when investigating the
internal validity of this experiment. Also, in this study, you will find that there is a possibility of
causal inference due to the fact that the risk behind giving the participants heroin may have
outweighed the benefits. (Lynne, 2008) The conclusion of the study also noted that heroin
maintenance might not have been the only factor that contributed to the improvement of their
health, socioeconomics and their drug use. (Lynne, 2008) It was determined that other outside
factors could have also carried some weight in reference to the end result in the study. Things
such as the participants lifestyle, genetics and other factors could have contributed to the
changes in the participants. Finally, there may have been other unknown variables that could
have also contributed to the overall health, socioeconomic status and their reduction of drug use.

Sampling

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The population studied included two groups of 40 patients. (Perneger, 1998) These groups
consisted of Geneva residents who had resided there since June, 1994 and who also had to be
20+ years old. (Perneger, 1998) In addition, they also had to be addicted to heroin for 2+ years,
and have used heroin on a daily basis. (Perneger, 1998) Social distress, poor health or both due
to their drug use had to be factored in, too. (Perneger, 1998) They also had to have two or more
previous unsuccessful attempts at drug treatment, participate in evaluation and discontinue
driving when starting the heroin maintenance program. (Perneger, 1998) The advantages to
choosing this group for sampling was the fact that they had been unsuccessful in other treatments
and this may be a last resort to help them with their health, social functioning and amount of
drug use. (Perneger, 1998) Also, the fact that they have been using the drug for an extended
period of time would also bring results that could heighten the accuracy when measuring drug
usage. (Ribeaud, 2004)

If they treated a user that had only been on heroin for a short period of

time, the study could have possibly caused those being studied to want to use heroin more
frequently than then they had been using or increase the amount of heroin each time they used.
(Ribeaud, 2004) Other disadvantages to the chosen sampling would include the fact that the
group is already in poor health and by giving them heroin could possible cause their health issues
to increase or add other health problems. (Ribeaud, 2004) Also, their lack of mentally stability
could make the results less viable because it is sometimes difficult to distinguish between mental
health issues and addiction. (Ribeaud, 2004) An important part of the selection that could be
considered as generalized could be in reference to the specific area in which the participants
reside. Communities with higher or lower incomes could have a large impact on the results of
the study. (Lynne, 2008) It would also be difficult to generalize the findings in this particular
group due to the strict requirements that are needed to attend treatment. (Lynne, 2008) If the

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strategies were altered, then the findings could change. For example, if the research included
addicts that did not use as much heroin as they were given in the trial, that could make their
addiction worse, not better. (Lynne, 2008)
Measurement
The key variables in this study measured the positive or negative effects on the subjects in
reference to self-reported drug use, health status and social functioning while on the maintenance
program. (Perniger, 1998) The frequency of overdoses were also noted. (Perniger, 1998) Other
variables include the type of risk behaviors were involved, such as HIV infection, the number of
days that they were ill in the past month and their health status. (Investigating, 1998) The
variables involved on the socioeconomic side included their work status, living arrangements and
the status of their social relationships. (Perniger, 1998) Also, monthly living and drug
expenditures were included as well as a source of income and criminal behaviors. (Perniger,
1998) At the beginning of the trial, the measure of health status appeared to be quite reliable
because they were examined by a doctor. (Ali, 1999) On the other hand, the validity of the
measure of self-reported drug use and social functioning may have been skewed because the
source of the information came strictly from the participant. (Ali, 1999) For example, if the
measure involved only health status, the validity of the measure would be much improved due to
the validity of the reports. (Ali, 1999) If the trial were to consider alternative measures, the
findings would be impacted by change. For example, if we were to reduce the amount of heroin,
that fact would skew the results of the study because the findings would be less accurate due to
the reduced amount of the drug administered to the participant. (Ali, 1999)

Data Collection

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The methods used to collect data for the experimental program was done in a quantitive
measure because the results of the data from the content was used to determine the outcome of
the trial. This data included police reports, health records, employment records, records from
social welfare agencies and interviews from the participants. (Perneger, 1998) The personal
information gathered involved information such as address, family information, personal and
family relationships, drug use, criminal history urine test results and psychiatric history.
(Perneger, 1998) The reason that this information is relevant is because it can aid in safe and
effective treatment and help monitoring the progress of the treatment. (Ribeaud, 2004) It also
can assist in identifying changes that needed to be made to provide better treatment in the future.
(Ribeaud, 2004) The strengths in the collected data would include the police reports and the
records from the social welfare agencies. (Perneger, 1998) The reason for that is because the
information in these would prove to be accurate because they come from professionals. The
others would be weaker because they involve self-reporting, which could raise an issue of
information bias. (Lynne, 2008) Self-reporting could also include withheld information from
the participant, which could also raise an issue of information bias. (Lynne, 2008)
Ethics and Cultural Consideration
An issue related to cultural competency includes the fact that the study was done in an area
of Switzerland which is known to have well-developed health and social service system. This
area includes a variety of services for addicts. If the trial was done in a lower economic area
with fewer services, the results may have been different. Also, each individual participant had
different medical and mental issues. Since these issues can vary, it is difficult to consider the
outcome of the study to be bias or non-bias. Ethical considerations in this trial fall under three
categories. These categories include consent, risk/benefit and confidentiality. Consent can be an

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issue because there is a question involving the mental capacity of the participant when they are
signing for consent to do the trial. An idea to correct the problem could be to stabilize the
participant to a degree where they are able to improve their decision-making capacity to sign
forms. Also the risk/benefit costs must be considered because of the consideration of whether or
not giving an addict heroin is risky behavior. Confidentiality protection is also a consideration
because it could include risks to their reputation, employability and insurability if personal
information about substance abuse and illegal activity leaks into the public.
Results and Implications
Overall, the controversial program did present some interesting findings. The long-term heroin users involved in
the study proved to be effective when three main factors are considered. These factors include drug use, mental health and
social functioning. (Perneger, 1998) Illegal activities also fared to be significant in this sample group. (Perneger, 1998)
The experimental participants also reduced illegal activities, which included their drug purchases and expenses, their
illegal income and they had committed fewer crimes. (Perneger, 1998) What did not change was the use of other drugs,
work status and housing situation. (Perneger, 1998) The study concludes by saying that the program was an overall
effective way to treat heroin users that have not been able to succeed in conventional drug treatment programs. (Lynne,
2008) The findings also concluded that this population could also benefit from other methadone maintenance programs,
which may help them to stop opioid use. (Musto, 2002) The findings of this study appeared to be limited because the
sampling choices were narrowed down to using participants who had to follow certain qualifications to enter the program.
(Lynne, 2008)
I cannot see this program as being too effective to the participants because it did not cover a very important factor,
which in my opinion, would have been to attempt to get the participants off of their drug habit. Looking at the
effectiveness of the trial from a different perspective could conclude that it did make considerable improvements in
stabilizing their lifestyle and overall health. (Perneger, 1998) Achallenge and barrier to the implementation of this

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intervention include the lack of funding for future trials because this study proved that the costs involved could be
expensive. (Lynne, 2008) This study concluded that heroin maintenance was far more expensive than methadone
maintenance because of the cost of attendance (three times per day) and the cost of injecting equipment over the orally
ingested methadone and other drugs used in the trial. (Ali, 1999) The United States healthcare system also has barriers in
treating drug abuse. (Musto, 2002) People who have medical and private insurance have limitations to coverage to assist
addicts to get off of drugs. (Musto, 2002) Asolution to this problem could involve a mandate in the Affordable Care Act
that would aid in helping those with addictions. (Musto, 2002) Another solution could be to educate a larger, and/or
younger audience to teach them the harms of drug abuse. (Musto, 2002) Finally, improving community based programs
aimed at bringing the awareness of heroin use in areas where there is an abundance of drug use and also developing
programs that could help people to understand that addiction is a disease and not a choice. (Musto, 2002)
In conclusion, The Randomized Trial of Heroin Maintenance Program for Addicts Who Fail Conventional
Drug Treatment was proven to be a success, because it provided and increased positive personal development for the
participant. However, the results proved to be the same when using comparable medications. Unfortunately, treating
those who are dependent on heroin with heroin is not socially acceptable in our society. Other studies are essential if we
want to continue the fight against substance abuse. In order to encourage the advancement of studies on drug abuse, we
need to bring the issue to the attention of our community leaders so they can bring the awareness to the political arena and
enlist the help of our politicians to start making changes to benefit our society.

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References

Ali, R., Auriacomb, M., Casas, M., Cottler, L., Farrell, M., Klieber, D., et al. (1999). Medically
Prescribed Narcotics to Drug Addicts. External Panel on the Evaluation of the Swiss
Scientific Studies, 23, 1-9. Retrieved April 12, 2013, from epes.com
Fuoco, M. (2012). A Heroin Addict Tells Her Story. Pittsberg Post Gazette, pp. 1,2.
Lynne, A. (2008). The Controversial Use of Heroin-Maintenance Therapy. The Debate
Continues Among Drug Misuse Experts. Retrieved April 10, 2014, from
http://voices.yahoo.com/the-controversial-heroin-maintenance-therapy-800365.html
Musto, D. F., Korsmeyer, P., & Maulucci, T. W. (2002). The Swiss Heroin Maintenance Trials.
One hundred years of heroin (pp. 6-16). Westport, Conn.: Auburn House.
Perneger, T. V., Giner, F., Rio, M. D., & Mino, A. (1998). Randomized trial of heroin
maintenance program for addicts who fail in conventional drug treatments. BMJ,
317(7150), 13-18.
Ribeaud, D. (2004). Long-term Impacts of the Swiss Heroin Prescription Trials on Crime of
Treated Heroin Users. Journal of Drug Issues, 34(1), 163-194.
Rubin, A., & Babbie, E. R. (1989). Research methods for social work. Belmont, Calif.:
Wadsworth Pub. Co..
The Detox Center. (n.d.). Brick Township, NJ Detoxification Services. Retrieved April 14, 2014,
from http://alcoholdetoxcenter.com/brick-township-nj-detoxification-services/

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