Cohen, Peter (2000), Letter to the Editors. Journal of Substance Abuse Treatment, Vol 19 2000, pp. 209-210.
© Copyright 2000 Peter Cohen. All rights reserved.


Letter to the Editors

Peter Cohen

Dear Editors,

Sally Sattel and Ernst Aeschbach (Journal of Substance Abuse Treatment, Vol.17, No 4, pp. 331-335, 1999) give a lengthy and detailed appraisal of the Swiss heroin trial. They conclude it does not withstand scientific scrutiny.

As the co- designer of the 1983 proposal for an Amsterdam based heroin maintenance trial (agreed upon by the City, refused by the national government), I sympathize with Satel and Aeschbach's concern for scientific scrutiny. I agree that the Swiss trial can not be the last word in the process of evaluation of heroin maintenance in different social and legal settings. Still, I have chosen not to address their many problems with the Swiss trials. Before I will discuss only two of their methodological points, I want to say that maintenance treatment is a class of social /medical intervention that suffers from intensive ideological noise. During the 1980's Western Germany struggled its way through widespread medical opposition to methadone maintenance, as did France during the 1990's. In 1983 Dutch national politics could not accept trials with heroin maintenance, but it could 15 years later.

Maintenance types of 'treatment' in a prohibitionist culture will be criticized by part of the medical and political establishment on grounds of principle. For many, complete cessation of drug use is the only worthwhile goal of any treatment, and no level of scientific or professional quality of any maintenance program will render such programs acceptable.

Reading Sattel and Aeschbach gives me the feeling that they dress their deeply principled opposition versus heroin maintenance in clothes of methodological fashion.

First, looking at the trial, they question its claims "about the superiority of heroin maintenance over conventional opiate treatment for heroin abusers, such as oral methadone maintenance and residential, or abstinence-oriented, care."

I have not seen such claims proclaimed by the Swiss, but if ever they might surface, they would not be relevant. The setting of heroin maintenance in modern drug treatment must prove that it improves the social or medical situation of a sizeable portion of its clients and that is able to retain a decent portion of them. Once this is proven, heroin maintenance can be a useful extension to the already accepted types of intervention in the drug treatment field. It does not have to be superior in the general sense; it should have its place amid a range of options that should be offered to potential clients. Even in the Netherlands, where (methadone) maintenance is the staple of treatment interventions in the area of frequent heroin use, drug free treatment is offered as an option. A minority of clients uses it, at moments in their career they need just that. 'Superiority' of any one-treatment intervention might only be relevant under conditions of limited choices.. The more choices a client has, the more she can adjust the right treatment modality to the right moment. These combinations may change overtime - although for some the first chosen modality or combinations there of might be spot on-. The quest for the 'superior' one treatment in this field, valid for all potential clients, can not have a happy ending.

My second point illustrates the earlier one. Satel and Aeschbach state that

"If heroin maintenance could be shown, through rigorous comparison with conventional treatment, to eliminate crime, illness, and drug use in intractable opiate abusers, it might justify consideration as a form of therapy."

In other words, the goals that heroin maintenance has to satisfy in order to be justifiable are impossible. I hope Satel and Aeschbach will never have to prove the 'superiority' of the treatment modalities they seem to like better than heroin maintenance, according to the multitude of standards they defend in their article and according to the treatment goals they stipulate for heroin maintenance. They might remain wordless.


Peter D.A.Cohen Ph.D