Current Issues Brief 3 1998-99

Alternative Treatments for Heroin Addiction

Paul Mackey
Social Policy Group
8 December 1998

Contents

Introduction

Selected Facts and Figures on Heroin

Tough on Drugs: the National Illicit Drugs Strategy

Developments in Treatment for Heroin Dependence

Endnotes

Introduction

The proposed trial of prescription heroin in the ACT did not proceed following its rejection by Federal Cabinet in August 1997. Much has occurred in the intervening period as the pressure has built on different players (particularly governments) to fill the void. For example, the Commonwealth Government has announced that the next stage of the National Drug Strategy, 1998-2002, will have as its main focus a National Illicit Drugs Strategy. In addition, most States and Territories have commenced trials of various treatments for heroin addiction such as naltrexone and New South Wales has announced that it is to introduce a United States' concept, the 'drug court'.

Although illicit drugs in general (and heroin in particular) raise issues on which many people have firm opinions, little hard data exists to inform public policy. For example, it is not known with any certainty how many people are regular users of heroin. The latest national data, collected in 1995, indicate that between 1 and 2 per cent of the population have used heroin, however, anecdotal information and some localised studies suggest that the number of users may be increasing and the average age of users falling. Although more than 236 kilograms of heroin were seized by law enforcement agencies in 1996-97, few shortages of the drug were reported on the street and it is not known how much heroin enters Australia each year. It is not yet clear whether the biggest ever seizure of 400 kilograms in October 1998 will impact on the quantity of heroin available on the street. Over 7100 arrests were made in 1996-97 for heroin-related offences, but arrests of users (4986) were more than double the arrests of suppliers (2154).

Increased public scrutiny following the abandonment of the ACT heroin trial together with an intriguing public relations and marketing campaign by proponents of rapid opiate detoxification (rapid withdrawal from heroin) using naltrexone have led to the commitment of funding for trials of various treatments for heroin addiction in most jurisdictions. As well as the official trials of these treatments, several clinics are providing, at considerable cost to patients, rapid opiate detoxification using naltrexone and other drugs.

The intense pressure on policy makers to find a 'quick fix' cure for heroin addiction and the claims made through the media for drugs such as naltrexone (e.g. 'I woke up cured of heroin'; 'success rate for detox drug hits 90pc') have tended to underplay the important role played by methadone in the treatment of heroin addiction. A recent paper issued by the Alcohol and other Drugs Council of Australia notes that methadone maintenance treatment is 'without competitor as the best researched of all treatments for opioid dependence'(1). Methadone maintenance is currently available in each State and Territory with the exception of the Northern Territory.

This Current Issues Brief provides an overview of developments since August 1997, including a selection of the latest statistics on heroin, details of treatments currently being trialed in various States and Territories and key elements of the National Illicit Drugs Strategy.

Readers seeking information on the situation prior to August 1997 are directed to the comprehensive Public Issues Kit produced by the Department of the Parliamentary Library in 1997 (Alternative Approaches to Managing Heroin Use: the ACT Heroin Trial and the International Experience). See also Illicit Drugs, their use and the Law in Australia, an Information and Research Services paper released in May 1997 which describes some of the major illicit drugs, their effect, their social and personal costs and the laws that govern them.

Selected Facts and Figures on Heroin(2)

Heroin Usage in Australia

The overall prevalence of heroin in Australia is not known with certainty. National household surveys conducted in 1988 and 1995 as part of the National Drug Strategy indicate that usage is generally stable at between 1 and 2 per cent of the population. However, there is some concern that there may have been both an increase in use since 1995 and a decline in the average age of users. Some local studies of regular drug users in Sydney, for example, indicate that the average age of heroin users is falling. Associated with this trend, these studies have detected an increase in the number of drug users who have switched from injecting amphetamines to injecting heroin. The results of a further national household survey, planned for 1998, will provide an indication of trends in these areas.

Costs of heroin use

The economic and social costs of heroin use are disproportionately high when compared to the low prevalence of heroin use in the Australian community. The economic costs arise from:

• loss of life through fatal overdoses
• treatment of overdose and other medical consequences of injecting drug use
• methadone maintenance and other methods of treatment for heroin dependency
• transmission of disease, including hepatitis B and C and HIV
• drug prevention activities
• law enforcement and judicial costs
• property crime and theft
• loss of productivity

In addition, heroin use can cause considerable social costs to users, their families and the community, through family breakdown, pain and suffering and loss of quality of life. It has been estimated that the costs of illicit drug use exceeded $1.68 billion in 1992(3).

Current trends in heroin use in Australia

• Studies indicate that the number of overdose deaths among heroin users has increased dramatically over the past two decades, by almost 700 per cent in the 15-44 age group, from 70 deaths in 1979 to 550 in 1995. Over the same period of time, there has been a noticeable rise in the purity of heroin reaching users in many parts of Australia.
• Researchers are unclear about the precise cause(s) of the increasing numbers of overdose deaths. While the increased purity of heroin is a factor, there are other contributing factors to take into account, including polydrug use (such as alcohol and benzodiazepines). Experts argue that the rise in the purity of heroin does not explain why the increase in overdose deaths has been greatest among older heroin users.
• Statistics indicate that 7140 arrests were made for heroin-related offences in 1996-97, comprising 2154 arrests of suppliers (providers) and 4986 arrests of users (consumers).
• Although cannabis still accounts for the greater proportion of total drug arrests, the latest statistics indicate that heroin is now a clear second, ahead of arrests for amphetamines, hallucinogens, cocaine and steroids. In 1996-97, heroin accounted for 8.40 per cent of total drug arrests, up from 6.19 per cent in 1993. Arrests for cannabis were 81.29 per cent of total drug arrests in 1996-97, down from 83.56 per cent in 1993.
• Some 236.5 kilograms of heroin were seized by Australian law enforcement agencies in 1996-97. Significant seizures included: Customs officials at Melbourne Airport located 23.7kg of heroin which had been concealed in carved wall hangings sent from Bangkok (11 October 1996), while 78kg of heroin was discovered in a joint operation by the Australian Federal Police, New South Wales Drug Enforcement Agency and the Australian Customs Service. The drug had been concealed in tins of pineapple, sent by sea from China, via Hong Kong (28 April 1997). Although significant, these seizures have been dwarfed by the seizure of 93kg of heroin in July 1998 and over 400kg in October 1998.
• Reflecting on the seizures in 1996-97, the Australian Bureau of Criminal Intelligence (ABCI) warned that 'few shortages [of heroin] were reported anywhere and law enforcement did not appear to affect prices on the street'. Further, it stated that 'although various attempts have been made, it is not possible to estimate with any accuracy the volume of heroin entering Australia'.
• It is estimated that over 80 per cent of heroin detected entering Australia originates in Southeast Asia. The incidence of seizure indicates that Sydney is the major importation and distribution centre for heroin in Australia.

Tough on Drugs: the National Illicit Drugs Strategy

The evaluation of the 1993-97 stage of the National Drug Strategy (NDS) concluded, in part, that:

The next phase of the National Drug Strategy, 1998-2002, has as its centrepiece a renewed focus on illicit drugs. Announced by the Prime Minister in two instalments, on 2 November 1997 and 16 March 1998, the National Illicit Drugs Strategy seeks to mount a balanced attack on both demand and supply and on minimising the harm caused by illicit drugs.

At its meeting on 7 November 1997, the Australian Heads of Government supported the new strategy agreeing on 'the need for strong and concerted national action to tackle head-on the social and economic impacts of drug use on the Australian community'(5).

The Ministerial Council on Drug Strategy, which comprises the Commonwealth, State and Territory Ministers for Health and Law Enforcement, expressed support for the National Illicit Drugs Strategy at its meeting on 4 May 1998. The Ministers endorsed the National Drug Strategy Committee as the appropriate body to prioritise and coordinate activity across all the National Expert Advisory Committees 'to ensure that policies, strategies and directions are consistent with the National Drug Strategic Framework'.

A National Expert Advisory Committee on Illicit Drugs has been established by Ministers to provide high level, expert advice to the National Drug Strategy Committee, the Australian National Council on Drugs (ANCD) and through them to the Ministerial Council on Drug Strategy. The new expert committee has been given the task of advising Ministers on priorities and strategies to address illicit drug issues, including prevention, education, supply control, law enforcement, research, treatment and rehabilitation(6).

Following on from the Prime Minister's announcements of 2 November 1997 and 16 March 1998, the Commonwealth Government announced in the 1998-99 Budget that it has committed $214.6 million over the years 1997-98 to 2001-02 towards the implementation of the National Illicit Drugs Strategy.

Some $95.5 million has been allocated for demand reduction and harm minimisation initiatives, including:

• establishment or enhancement of non-government treatment facilities ($50.3 million over 4 years)
• a community grants program for local drug prevention and education projects ($4.9 million over 3 years)
• a comprehensive community wide education and information campaign ($17.6 million over 3 years)
• establishment of a 'one-stop shop' for dissemination of information on illicit drug issues ($2.5 million over 5 years)
• more than $7 million over four years for research and evaluation
• training for frontline professionals and dissemination of best practice ($3.1 million over 4 years)
• data collection and monitoring ($3.7 million over 4 years)
• support for a range of activities aimed at identification, promotion and dissemination of best practice in the treatment of illicit drug dependence ($2 million over 3 years), and
• the establishment of an Australian National Council on Drugs and associated structures ($3.7 million over 4 years).(7)

Further funding will be directed to supporting supply reduction initiatives, including:

• $15.5 million over 3 years to the Australian Federal Police to establish three mobile strike teams. These teams will be deployed throughout Australia and will assist in targeting and proactively investigating major drug syndicates operating anywhere in Australia
• Australia's coastal surveillance and detection capacity in the Torres Strait will be enhanced by funding of $6.7 million over 3 years which will increase night surveillance, helicopter flying hours and marine surveillance
• a National Heroin Signature Programme is to receive funding of $3.9 million over 3 years. This programme will identify trafficking patterns for heroin, improve research into drug-crime links and increase funding for informant handling and witness protection
• $7.3 million is to be spent over 3 years to improve information technology capabilities and communication. This initiative will provide for a secure, high-volume IT network for the flow of intelligence and operational information between the relevant Commonwealth law enforcement agencies
• the capacity of the Australian Financial Transaction Reports and Analysis Centre to monitor suspicious financial transactions will be enhanced by funding of $1.5 million over 3 years
• funding of $1.5 million over 3 years will enable the recruitment of additional intelligence analysts to work in the Australian Customs Service, and
• the Commonwealth Government is to spend $7.5 million over 3 years on additional cargo examination capacity, supported by a new electronic cargo profiling system.(8)

It was announced in the course of the recent election campaign that the Government would provide additional funding of $23.4 million over four years for a further four mobile strike teams (bringing the total number to 10 strike teams) in Sydney, Perth, Adelaide and northern Australia, based in Cairns.

Developments in Treatment for Heroin Dependence

The Ministerial Council on Drug Strategy reached agreement on several significant issues at its meeting on 31 July 1997. One of these was the proposed trial of prescription heroin in the ACT, which did not proceed following Cabinet discussions. However, the meeting also provided approval for trials of other treatment options using five pharmaceuticals: naltrexone; LAAM (levo-alpha-acetylmethadol); buprenorphine; slow-release oral morphine and tincture of opium. Trials were proposed for New South Wales, Victoria, South Australia and the ACT. Papers are included in the Department of the Parliamentary Library's Public Issues Kit on Alternative Treatments for Heroin Addiction, which provide an overview of the uses of each pharmaceutical in the treatment process and contain details on several of the trials which are currently underway.

An overview of recent developments in each State and Territory is provided below, including a summary matrix of trials which have received funding or are expected to receive funding. It should be noted that the trials are in various stages of development in the different jurisdictions and consequently the available information varies on each trial. Funding for the trials has been provided by State and Territory governments. A national evaluation of the trials is to be undertaken by the National Drug and Alcohol Research Centre (NDARC), which is expected to report in 2001. The details below on the trials in each jurisdiction are drawn primarily from an article by Dr Gabrielle Bammer (which is included in the kit) and information provided by the Commonwealth Department of Health and Aged Care and NDARC.

The matrix below provides a summary of the treatments for heroin dependency currently in use, being trialed, or planned for trial in each jurisdiction. Also included are other initiatives under consideration such as drug courts and legal injecting rooms.

* levo-alpha-acetylmethadol

**slow-release oral morphine

New South Wales

Naltrexone

Two clinical trials of rapid opiate detoxification using naltrexone are underway in New South Wales, one at Westmead Hospital (50 patients) and the other at Sydney Hospital (31 patients). Both trials are in two stages. Westmead Hospital is trialing rapid opiate detoxification both with and without anaesthesia and has recruited participants from among heroin users and methadone patients, while participants at Sydney Hospital are trialing the technique under sedation. Participants in the Sydney Hospital trial have also been recruited from among heroin users and methadone patients.

Preliminary data from stage one of the Sydney Hospital trial have been described as 'encouraging' by the New South Wales Minister for Health(9). Data from stage one of both trials will be compared before the NSW Government proceeds with stage two, a full randomised clinical trial at Westmead Hospital.

Buprenorphine

Participants in a randomised controlled trial are allocated to treatment with either buprenorphine or methadone. A cost-effectiveness study of each drug will be conducted in addition to comparisons on outcomes for participants including health, social functioning, crime, drug use, and HIV and hepatitis risk behaviour.

Buprenorphine is also the subject of a randomised controlled trial which plans to evaluate the efficacy of the drug as a withdrawal treatment at the conclusion of methadone maintenance.

Drug Court

The New South Wales Government announced recently (10 September 1998) that the State would commence a two year trial of a 'drug court' in 1999 at a cost of $5 million. Several hundred drug courts have been established in the United States since the late 1980s and are regarded there as a successful innovation. Details released to date about the New South Wales version indicate that heroin users who plead guilty will be sentenced by the drug court to 12 months rehabilitation instead of prison and will be expected to undergo regular urine tests and supervision to ensure that their heroin use has ceased. Failure to comply with the conditions of rehabilitation will result in sanctions being imposed by the court, including a prison sentence.

Announcing the initiative, the NSW Premier stated that eligible participants would be drug dependent, facing a prison term, be prepared to admit their guilt and willing to participate in the program. Those eligible to appear before the drug court will be facing charges for offences which include non-violent theft, possession, fraud or forgery, stealing from a person, unarmed robbery providing there is no physical harm involved, or dealing in quantities of drugs below the indictable limit. Offences involving violence or offenders involved in sexual offences will be excluded from the drug court process. Legislation to establish the drug court is expected to be introduced during the current sittings of the State Parliament.(10)

Legal Injecting Rooms

Legal heroin injecting rooms, commonly described as 'shooting galleries' have received considerable attention in New South Wales. The Royal Commission into the New South Wales Police Service (Wood Royal Commission) recommended the consideration of legal injecting premises and invited consideration of amendments to the NSW Drug Misuse and Trafficking Act 1985 to enable the establishment of such premises. The Royal Commission identified several reasons in favour of the establishment of legal injecting premises but also warned that close supervision and strict guidelines would be necessary elements of any such initiative.(11)

A NSW Parliamentary Committee was established to consider this proposal of the Wood Royal Commission but voted six members to four against a trial of legal injecting rooms. The NSW Premier had earlier announced that the Government would proceed with a trial only if it received bi-partisan support. Subsequently, the issue has received consideration from local councils, including the South Sydney Council which is investigating whether it has the power to establish such premises under regulations permitting needle exchanges.(12)

Victoria

Five trials of alternative treatments for heroin dependency are underway or planned in Victoria, all of which are overseen by Turning Point, the Victorian drug and alcohol research centre.

Naltrexone

A trial comprising 208 volunteers, previously heroin dependent and who are post-withdrawal, is to examine the effectiveness of naltrexone in reducing relapse rates and improving the outcomes of treatment in such areas as risk taking behaviour, criminality, health status, social functioning and psychosocial adjustment. The sample group will be divided in half with 104 participants receiving naltrexone treatment and 104 as the control group. Participants in the trial are to be recruited from a variety of post-withdrawal services around Melbourne.

LAAM

Treatment for heroin dependence using levo-alpha-acetylmethadol (LAAM) is to be evaluated in primary care (general practice) and specialist settings. LAAM is suitable as a substitute for methadone in maintenance treatment for heroin dependency but is prescribed on a three times per week basis rather than methadone's daily dosage. The Victorian trial will introduce clinical guidelines and training programs and examine the cost effectiveness of the drug. The trial will also monitor the groups for whom LAAM is most successful as a treatment option.

The trial will involve specialist doctors and GPs with extensive experience in prescribing methadone who will be trained in the management of heroin dependence using LAAM. Pharmacists who are experienced in dispensing methadone will be trained in dispensing and monitoring procedures for LAAM. Guidelines are to be developed to assist the doctors and pharmacists. Volunteer participants will be recruited from heroin users eligible for the methadone program and patients already in a methadone program. Volunteers who are deemed suitable by their doctor will be randomly selected to receive treatment with LAAM or methadone.

Buprenorphine

Buprenorphine is the subject of two trials in Victoria. The first trial will evaluate buprenorphine in the same way as that outlined above for LAAM (i.e. as a means of withdrawing from heroin). The other trial will assess the efficacy of buprenorphine as a means of withdrawal from methadone. This trial is to be conducted in three stages. Stage one is a survey of methadone clients, their pharmacists and methadone providers. Stage two is a pilot dosing study which aims to determine the best way of transferring patients from methadone to buprenorphine, including appropriate dosages. Stage three is a randomised controlled trial designed to test the efficacy of buprenorphine as a methadone withdrawal agent. Participants who are withdrawing from methadone will be randomly assigned to receive reducing doses of buprenorphine or reducing doses of methadone. The dosages established in stage two will be used for the stage three trial.

Slow-Release Oral Morphine

Slow-release oral morphine is a well-established treatment for pain but more research is required to evaluate it as a treatment for heroin dependence. This trial, which is expected to begin by the end of 1998, will evaluate the safety, efficacy and cost effectiveness of slow-release oral morphine. The project will have three components and will comprise 20 heroin dependent participants and 20 methadone-maintained participants. A 24 hour oral morphine is to be used in the trial and outcomes to be measured include treatment compliance, dose adequacy, tolerance, adverse events and morphine-related side effects.

Related studies

Two further studies are planned involving methadone, LAAM and buprenorphine. One study will assess changes in the thinking capacity (cognition) of patients undergoing treatment with these drugs. The other study will investigate the effects on the driving ability of patients undergoing treatment with the drugs.

Legal injecting rooms

The Lord Mayor of Melbourne has indicated that a decision on legal injecting premises for heroin users is expected to be made by council in the near future. The City of Greater Dandenong considered establishing legal injecting rooms in 1997 but after receiving advice that this may contravene the provisions of the Victorian Drug Poisons and Controlled Substances Act 1991, has reportedly suspended any firm decision.(13)

Drug Court

The Lord Mayor of Melbourne has called for the establishment of a drug court in Victoria.

South Australia

Naltrexone

A three year trial of rapid opiate detoxification using naltrexone has received funding of $466 000 from the South Australian Government. The trial is to be undertaken by the Drug and Alcohol Services Council in collaboration with the Royal Adelaide Hospital and the University of Adelaide. One hundred patients are to be recruited for the trial which will compare two methods of withdrawal from heroin. Participants will be randomly assigned to two groups. Fifty patients will receive rapid opiate detoxification under anaesthesia, followed by twelve months of monitoring, including daily doses of naltrexone. The other group of fifty patients will receive the standard in-patient detoxification procedure (5-7 days) at Warinilla Clinic, followed by twelve months of monitoring including daily doses of naltrexone.

Participants to be recruited for the trial must be: 18 years and older; current heroin users; dependent on heroin; willing and able to participate in a detoxification procedure followed by a twelve month aftercare program; and willing to accept random allocation to treatment. The aftercare component of the trial will involve four face-to-face interviews at one, three, six and nine months after detoxification. During these interviews, blood tests will be taken, current health status and social functioning will be assessed and the effects of naltrexone monitored.

LAAM

The trial of LAAM in South Australia aims to compare LAAM maintenance with methadone maintenance among participants who have been stabilised on methadone for at least six months. Participants will have three months on each drug and will be offered a free choice between the two drugs at the conclusion of the trial.

Buprenorphine

A trial of buprenorphine as an alternative maintenance treatment for heroin dependency is underway in South Australia. This trial is similar to a trial in New South Wales. A further trial of buprenorphine is planned which will evaluate the drug's efficacy as a means of withdrawal from methadone.

Tincture of opium

South Australia is collaborating with clinicians in Thailand to compare the efficacy of tincture of opium with methadone maintenance in a randomised controlled trial. If judged to have value as a maintenance treatment, its use in Australia will be further examined.

Queensland

Naltrexone

The Queensland Government has recently announced that it is to commit $250 000 for a trial of naltrexone as a treatment for heroin dependency. The trial will be conducted by the director of drug and alcohol services at Royal Brisbane and Prince Charles hospitals, Professor John Saunders. Trial participants will receive either rapid detoxification under general anaesthetic, or accelerated detoxification using sedation or form part of a control group using methadone.

Western Australia

Naltrexone

The Western Australian Government has allocated $180 000 to two trials involving naltrexone. Dr George O'Neil has conducted an independent study of 750 heroin users since June 1997. A review of his first 100 patients has reportedly revealed that more than 75 per cent were positively managing their addiction after six months of treatment with naltrexone. To date, funding of $60 000 has been provided to Dr O'Neil's project by the state government for data gathering and analysis. The commitment of further funding to this project is currently under consideration. Funding of $20 000 has been allocated to the Department of Psychiatry at the University of Western Australia.

Australian Capital Territory

Naltrexone

Naltrexone is the subject of two trials in the ACT, which are examining its efficacy in withdrawal from heroin and withdrawal from methadone. ACT Community Care (ACTCC) has been contracted to undertake a trial of accelerated detoxification from methadone using naltrexone. ACTCC has subcontracted the research and investigation services of the National Centre for Epidemiology and Population Health (NCEPH). The trial is a multicentre study involving the ACTCC Alcohol and Drug Program's Detoxification Unit at Canberra Hospital and the Langton Centre in Sydney.

This trial consists of 15 methadone maintained patients (from the ACTCC Methadone Maintenance Program) who will be inducted onto naltrexone using naltrexone accelerated detoxification. The trial will document the severity of withdrawal, acceptability and rate of successful completion. Subjects will be monitored for three months to review their experience of detoxification and success in maintaining naltrexone maintenance and avoiding relapse to heroin use. A report and recommendations on a future trial will be made to the ACT Department of Community Care.

The National Centre for Epidemiology and Population Health has been contracted to conduct another trial which will examine the use of naltrexone and buprenorphine in the management of heroin withdrawal. NCEPH is to subcontract the ACTCC's Alcohol and Drug Program to provide clinical support for the trial, which will comprise 20 dependent heroin users plus five additional subjects. The trial will: identify the range of buprenorphine doses required to alleviate heroin withdrawal symptoms; identify the patient characteristics which impact upon the medication requirements of heroin withdrawal; and examine the acceptability to patients and clinicians of a naltrexone induction protocol.

Buprenorphine

See details above of NCEPH trial of buprenorphine and naltrexone in the management of heroin withdrawal.

Legal Prescription Heroin

Australia

Although Federal Cabinet's decision of August 1997 led to the abandonment of the proposed trial of prescription heroin in the ACT, calls for a trial have persisted. Dr Alex Wodak, President of the Australian Drug Law Reform Foundation and Director of the Alcohol and Drug Service at Sydney's St Vincent's Hospital, has been an outspoken proponent of such a trial as has the ACT Health Minister Michael Moore. The Lord Mayors of Australia's capital cities, meeting recently in Brisbane, have unanimously supported trials of prescription heroin. The mayors also supported legal injecting premises for heroin users. In addition, the Western Australian branch of the National Party voted at its annual state conference in August 1998 to support a controlled trial of prescription heroin.

Overseas

Trials of legal prescription heroin have been conducted in Switzerland during the past six years. A comprehensive collection of articles and reports on the Swiss trials can be found in the Department of the Parliamentary Library's Public Issues Kit No. 1 1997-98: Alternative approaches to managing heroin use: the ACT heroin trial and the international experience.

Trials of legal prescription heroin have also received attention in other countries. For example, the Netherlands, Denmark and Luxembourg are all considering following the Swiss approach to managing heroin use. Influenced by the results of the Swiss trials, the German Medical Council unanimously resolved earlier this year that heroin should be made available by doctors to a select group of heroin users. The Council has approached the Minister for Justice to address the legal issues involved. The German Minister for Health disagrees with the Council, preferring methadone maintenance to treat heroin dependency.(14)

The Health Commissioner of Baltimore in the United States has supported calls by the John Hopkins University for a research study of prescription heroin for 'hard-core' heroin users who have failed other forms of treatment.(15) The Mayor of Baltimore was quick to make it clear that the city's administration had no intention of supporting such a project.(16)

Canada is reportedly planning to introduce trials of legal prescription heroin in several cities. Canadian scientists and doctors who are members of the North American Heroin Trial Working Group are drafting the framework for a heroin maintenance trial. Health Canada (the Canadian Health Department) agrees that research is needed in this area, while Vancouver's chief of police has also supported the moves for a trial of prescription heroin.(17)

Endnotes

1. Commonwealth Department of Human Services and Health, quoted in Methadone treatment: an ADCA Issues Paper, Alcohol and other Drugs Council of Australia, 1998.
2. The information in this section is drawn from: Australian Bureau of Criminal Intelligence, Australian Illicit Drug Report 1996-97, published in December 1997; and E. Single and T. Rohl, The National Drug Strategy: mapping the future. An evaluation of the National Drug Strategy 1993-97, AGPS, Canberra, 1997.
3. Collins, D. and H. Lapsley, The Social Costs of Drug Abuse in Australia in 1988 and 1992, AGPS, Canberra, 1996.
4. Single, E. and T. Rohl, The National Drug Strategy: mapping the future. An evaluation of the National Drug Strategy 1993-97, AGPS, Canberra, 1997, p. 40.
5. Council of Australian Governments Meeting, Communique, 7 November 1997.
6. Ministerial Council on Drug Strategy, Joint Communique, 4 May 1998.
7. Budget 1998-99, Fact Sheet 1: Investment in Preventive Public Health Measures, pp. 4-5.
8. Tough on Drugs: Fact Sheet: Attacking the Drug Barons, 2 November 1997.
9. NSW Parliamentary Debates, 9 September 1998, pp. 38-9.
10. NSW Parliamentary Debates, 10 September 1998, p. 31.
11. Royal Commission into the New South Wales Police Service, Final Report, May 1997, p. 226.
12. The Health Report, 3 August 1998.
13. Sunday Age, 21 June 1998.
14. British Medical Journal, 4 April 1998, p. 1037.
15. Baltimore Sun, 10 June 1998, p. 1A.
16. Baltimore Sun, 12 June 1998, p. 1A.
17. Globe and Mail, 29 July 1998, p. A6.

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