Route-Dependent Subjective Effects of Medical Heroin in HAT: Implications for Treatment Trajectories

Background

The attraction to addictive drugs is often tied to their pleasurable effects, strongly influenced by how they are administered.

Heroin-Assisted-Treatment (HAT) provides supervised medical-grade heroin (diacetylmorphine - DAM) to individuals with chronic heroin dependence for whom standard opioid agonist treatments did not yield sufficient beneficial outcomes. 

HAT offers flexibility in administration routes, accommodating various patient needs, especially when venous access is challenging. However, limited research has explored patient perceptions of DAM, particularly regarding the transitions in the administration methods. Our study examines these experiences within Norway's time-limited HAT program, focusing on how different routes impact the patients' subjective perceptions and treatment trajectories.

Methods 

Semi-structured in-depth interviews were conducted with 21 participants, including those receiving IV, intramuscular (IM), and oral tablets (PO) DAM. A longitudinal trajectory analysis was performed on a subset (N=14 at 8 months, N=10 at 18 months) to track changes over time. Interviews were collected between March 2022 and July 2023. Transcripts were analyzed using a flexible inductive thematic approach (Braun et al. 2020).

Results

HAT participants tend to remain in the program, even after switching administration routes. Preliminary qualitative results revealed four primary themes: (1) Positive perceptions of DAM’s quality and effectiveness in suppressing cravings and reducing the allure of street drugs. (2) Divergent views on the 'rush'. While some valued the initial 'rush' from IV, others prioritised the stability and 'calm' effect of IM. Oral DAM was perceived as less intense. (3) Practical factors like vein accessibility influenced administration route transitions, but overall treatment value remained high. (4) Over time, attitudes shifted, with initial dissatisfaction evolving into adaptation. Participants reported enhanced functionality and gratitude for the HAT program 8-18 months into treatment.

Conclusions

These findings enhance our understanding of DAM's subjective effects, influenced by different administration routes. HAT and DAM appear to serve different purposes for patients based on administration route preferences. Those valuing the 'rush' prefer IV, while others find the transition to 'calm' through IM or PO desirable. Importantly, the program has low attrition rates, and patients adapt quickly to new routes and subjective effects, although they may not initially find all aspects ideal. This suggests HAT may have a higher retention rate compared to alternatives for this group of 'hard-to-treat' and 'hard-to-reaxch' patients. This knowledge can guide customized intervention strategies within HAT programs, optimizing treatment trajectories and improving outcomes and functionality.