German doctors vote to prescribe heroin to misusers

Heroin should be distributed to a select group of longstanding addicts, the German Medical Council unanimously decided last week. The council has now applied to the minister of justice to enable opiates to be legalised in a strictly medically controlled context.

Dr Ingo Flenker, a member of the German Medical Council, said that the decision had been influenced by the recent results from Switzerland that showed the effectiveness of such an approach. Several other countries, including Australia, Denmark, Luxembourg, and the Netherlands, are also considering following Switzerland's example.

The Swiss trial was initiated by the department of social and preventive medicine at the University of Zürich in 1992. The project included more than 1000 heroin misusers who were all aged 20 or younger, had been addicted to heroin for at least two years, and were resistant to treatment.

The results showed that it is feasible to provide heroin by intravenous injection at a clinic, up to three times a day, seven days a week. This was done while maintaining good drug control, good order, client safety, and staff morale (BMJ 1998; 316:639). Conditions such as depression, malnourishment, and anaemia decreased during the study period. Simultaneously, social conditions were much improved: by the end of 1996 unemployment among the group in question had dropped from 44% to 20% and full time employment had risen from 14% to 33%. Six months into the study, homelessness in the group had ceased to be an issue.

In the Swiss trials, heroin was prescribed as part of a comprehensive social and psychological intervention. Dr Flenker stressed that such a multidisciplinary approach was essential for such a programme to work - a concept rarely successful in Germany. Those who will be included in the German programme will have a longstanding addiction to opiates, had several unsuccessful attempts at withdrawal, be in acute danger of social damage, and be compliant with treatment.

The German public's response has been positive. According to the newspaper Die Woche, 55% of Germans agree with the idea of heroin misusers receiving the drug directly from a doctor. The German minister of health, Horst Seehofer, disagrees with the council's decision and feels that methadone substitution is a better approach. However, his opinion will not influence the decision of the minister for justice.

Déirdre Cooper-Mahkorn,

Bergisch Gladbach,

Germany