Evaluation of treatment with prescribed heroin in Denmark

Full report in Danish: Evaluering af behandling med lægeordineret heroin i Danmark

Heroin-assisted treatment (HAT) is a specialized approach to treating individuals with chronic and severe opioid use disorder. It involves treatment with pharmaceutical heroin (diacetylmorphine) in a clinical setting, typically twice daily. HAT has been available in Denmark since 2010 and is currently available at five clinics throughout the country (Copenhagen, KABS Hvidovre, Odense, Esbjerg, and Aarhus).

The purpose of the report is to conduct an evaluation of the Danish HAT program. The report includes how the program has evolved since its implementation in 2010, program challenges from different perspectives and potential areas for improvement, particularly as it relates to patient dignity. The evaluation offers insights into patient outcomes while in treatment, staff and patient impressions on treatment, staff opinions on the treatment guidelines, and operational differences between the five clinics. This evaluation did not conduct a cost-benefit analysis, nor does it offer recommendations for how to update clinical practices guidelines. Such evaluations are outside the scope of this report. The Norwegian Centre for Addiction Research (SERAF) has responded to the task from the Danish Health Authority to be an independent evaluator of the Danish HAT program. The Centre for Alcohol and Drug Research at Aarhus University has contributed to the work on the qualitative sub-study.

In the document “Ansvar for Danmark. Det politiske grundlag for Danmarks regering” [Responsibility for Denmark. The political basis for Denmark's government], published in December 2022, the chapter on dignity indicates the government will "follow up on the evaluation of the program with prescribed heroin and implement measures that allow for consideration of new efforts that can ensure more dignity for, for example, people with significant substance abuse problems." As such, this report examines multiple aspects of HAT, exploring how patient dignity is upheld within treatment.

This evaluation found that several aspects of HAT can improve patients' dignity. First and foremost, HAT adds additional options in the treatment of opioid use disorder, and these options can be considered an improvement of dignity for the patient group. Dignity is also experienced by the patients as the clinics for prescribed heroin constitute a safe place with highly qualified staff. This evaluation of the Danish HAT program also found that treatment appears to be beneficial for a small group of patients in treatment for opioid use disorder. Based on information from the patients, the treatment has been successful in reducing drug use, offering long-term treatment retention, and reducing criminal activity. However, the number of patients enrolling since the start of treatment has declined, which may be due to several factors.

Interviews with patients and staff support that the treatment helps meet the needs of a vulnerable group of patients in Denmark. Nevertheless, staff reported challenges including structural, individual, and treatment-related barriers, and lack of accessibility. Structural barriers included slow and complicated referral and enrollment procedures, length of required prior enrollment in traditional opioid agonist therapy, and that HAT is often considered a last resort by many. Further, individual barriers included prejudice and stigma related to HAT, both among patients and professionals, which is often linked to lack of knowledge and information about HAT as a treatment option. Lastly, staff reported barriers within HAT, such as the current inclusion criteria and limited access to treatment, both in terms of the geographical location of the clinics, opening hours, and the waiting time that many patients experience between opening hours.

Staff and patients provided several suggestions for improving the treatment, including the potential to further promote qualified and holistic patient care by making opening hours more flexible, improving staffing levels, fostering professional development, and ensuring support for the social aspects of the treatment. The suggestions reflect how the reported challenges in HAT were often related to shortage in staff resources and the effect it would have on patient contact, levels of conflict, and implementation of rules and sanctions. Thus, the staff indicates the importance of time and resources to offer qualified treatment and create a trusting relationship with the patients. For some patients, this relates to the often-sensitive balance between providing safe treatment alongside concurrent drug and alcohol use outside treatment, and desire for intoxication.

This report also found that the clinics function similarly but also with notable differences. The staff reported limited exchange of experiences and competencies between clinics. Increased exchange, collaboration, and sharing of experiences and competencies are advocated by staff across clinics and has the potential to strengthen the clinics and streamline their operational practices. Furthermore, the clinics mainly operate separately from traditional opioid maintenance treatment. Enhanced integration could potentially optimize the use of staff resources and competencies, improve referrals into HAT, and reduce stigmatization. However, ‘integration’ of treatment interventions can refer to both physical incorporation into clinics and conceptual acknowledgment within a treatment system. HAT clinics require specialized staff and facilities, and it is unlikely that HAT clinics could simply be integrated into existing treatment clinics. An exploration of how potential integration could be considered, but this lies outside the scope of this report.

Lastly, this report included an evidence summary regarding take-home heroin-assisted treatment (meaning that patients are able to avoid daily visits to the clinic and have doses that they can take home with them). The provision of take-home heroin is rare, and only available on a small scale in two countries. The literature that exists shows that it appears to be an acceptable and desired option for a small number of stable patients. However, the evidence regarding the safety and effectiveness of take home heroin treatment is not supported by a strong evidence base.

Overall, the findings from this evaluation report support that for a small number of vulnerable patients, heroin-assisted treatment can offer dignified treatment for opioid use disorder that reaches beyond traditional treatment options.