Oslo 21st of June 2011 Dias 1 For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Treatment with medical prescribed heroin – experiences from Denmark Katrine Schepelern Johansen Post.doc Department of Anthropology University of Copenhagen

Oslo 21st of June 2011 Dias 2 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Program The research project on the Danish program for medical prescribed heroin Short presentation of the Danish program Why a program for medical prescribed heroin in Denmark? What has influenced the Danish program? Experiences this far Organization Staff Clients The future

Oslo 21st of June 2011 Dias 3 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology The research project on the Danish program for medical prescribed heroin Anthropological research project on the process, implementation and execution of the treatment From August 2008 to July 2012 A broad, holistic picture of the program for medical prescribed heroin in Denmark – including all five clinics No qualitative dimension in any of the other research projects → filling out a gab in knowledge on clients’ and staffs’ views on the treatment, and on the everyday life at the clinics A better picture of the relation between heroin and the social treatment Specific knowledge on the organization in a Danish context

Oslo 21st of June 2011 Dias 4 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Short presentation of the Danish program The final legislation was accepted in the Danish parliament spring 2008 Target group Clients who, despite maintenance treatment with methadone, continue to have an injectable abuse of illegal opioids No serious, un-treated, psychiatric disorders Over 18 years old Women who are pregnant or who plan to become pregnant can not be accepted in the program

Oslo 21st of June 2011 Dias 5 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Short presentation of the Danish program The heroin can only be administered through injection Clients should be able to inject themselves; either iv or im Clients can receive two doses a day (morning and afternoon) and will receive methadone for the late evening and night Max dose of heroin is 450 mg x 2 (but individual suspension from this has been given in a few cases) The treatment with heroin should be supplemented with social treatment

Oslo 21st of June 2011 Dias 6 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Short presentation of the Danish program Five clinics: Copenhagen, Hvidovre (the old Copenhagen municipality (amt)), Odense, Esbjerg and Århus The decision was taken with reference to a number of international research projects which all had shown a superior effect of heroin compared to methadone on ao physical health, mental health, use of street drugs, criminality… Contrary to other countries the introduction of heroin in Denmark was not done as a trial but as a regularly treatment mode (except in Århus)

Oslo 21st of June 2011 Dias 7 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Why a program for medical prescribed heroin in Denmark? Has been discussed since the first Swiss projects in the mid 1990s Continued rejection – last time after a hearing in the parliament in 2007 (Teknologirådets høring) Could the same result be obtained by optimized – medical and social – treatment with methadone?

Oslo 21st of June 2011 Dias 8 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Why a program for medical prescribed heroin in Denmark? Accepted in the spring 2008; after newspaper articles in Berlingske Tidende and Pia Kjærsgaard’s visit at Vesterbro (the open drug scene in Copenhagen). The dominant history was the humiliating, degrading lives of heroin users The envisioned target group of the politicians was people living on the streets, selling drugs, prostituting themselves, breaking in to apartment and houses Expected effects on these parameters In the subsequent bureaucratic work with the guidelines the actual target group chanced slightly: From hard to reach to hard to treat

Oslo 21st of June 2011 Dias 9 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology What has influenced the Danish program? Literature review: Treatment with heroin can have superior effect compared to treatment with methadone – especially drawing on the results from The Netherlands and Germany (the review being published before the results from RIOTT) The effect is probably not due to the pharmacological effect of the heroin but rather because treatment with heroin makes the treatment more attractive to clients engaged in heavy drug abuse That it will be treatment for a small group of clients Second line treatment (subutex and methadone being first line)

Oslo 21st of June 2011 Dias 10 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology What has influenced the Danish program? Based on the treatment principles documented to be efficient in the international research (injecting, supplementing methadone ordination) – but excluding other wishes The Danish policy has been worried about criminality directed towards the clinics and the transport of the drug → high level of security, surveillance – and control The Danish planners have had close contact to the British RIOTT, and the guidelines draw heavily on the protocol from RIOTT The local planners on the municipality level have also been inspired by the set up used in Germany, ao in relation to rules and regulations

Oslo 21st of June 2011 Dias 11 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology What has influenced the Danish program? Medicalization Focus in the official guidelines is on the health issues, control with the drug, safety…(thus transforming the morally suspect substance heroin into a technical problem) Nurses and doctors are the primary staff groups in this treatment Drug (ab)users → patients ”Medical specialist task” Heroin → DAM (Diacetylmorphin) The decision to introduce the treatment mode is based on a range of positive results from abroad – but is also limited by them

Oslo 21st of June 2011 Dias 12 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Experiences this far – organization Five clinics: Esbjerg, Århus, Odense, København and Hvidovre Clinic only for heroin (København) or together with clinics for methadone (others) The group of other users in the clinics Possibilities and limits for being intoxicated Supervision and scoring of the clients before, under and after the injection The supplementing social treatment The differences – to a large extent – mirror existing differences in treatment approach more generally

Oslo 21st of June 2011 Dias 13 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Experiences this far – staff Intoxication – how much is acceptable? Intoxication – should there be sanctions? Intoxication → over dose ( → potentially death) Groin-injection – is that acceptable? Groin-injection – what would be the consequences if not allowed? What aspects of the treatment is most important (and should therefore be prioritized in the daily work with limited resources) – the medical or the social dimensions of the treatment? What is the overall goal for the treatment? Harm reduction

Oslo 21st of June 2011 Dias 14 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Experiences this far – clients Clients enrolled in the program are generally very pleased with the program Most clients state their reason for enrolling in the program as dissatisfaction with methadone treatment Thus ascribing the positive effect to the heroin in it self Clients tell about less criminality and prostitution And better health And a less stress-full life

Oslo 21st of June 2011 Dias 15 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Experiences this far – clients Complains: Control and supervision Still needing to take methadone Very demanding to show up two times a day – difficult to find time and energy to anything else

Oslo 21st of June 2011 Dias 16 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology The future Still only few clients enrolled in the program – app. 120 – expected Change in dispensing method or take home doses? Very expensive treatment (app dkr pr year pr client) Are the effects worth the cost? What about clients not within physical range of the few clinics? Is it to late? Most clients today are involved in poly drug use that includes cocaine and benzodiazepines. Can heroin (and structure) also address those ailments? Will the introduction of heroin as a treatment drug lead to a change in the perception of heroin – among drug users and among the general population?

Oslo 21st of June 2011 Dias 17 Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Vis” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato, og ”Enhedens navn” i Sidefod Department of Anthropology Thank you for your attention! For futher information, feel free to contact: Newsletters about the project (in Danish): viden/heroinforskning.aspx