"Heroin Assisted Treatment (HAT) is an alternate treatment modality for people for whom more traditional forms of OST have been ineffective. HAT is currently delivered in seven countries worldwide (Switzerland, Canada, Germany, Holland, Denmark, Luxembourg and the UK) with the longest standing programme operating in Switzerland. The service usually comprises provision of synthetic medical grade heroin (diacetylmorphine) for supervised self-injection, under medical supervision in a clinical environment. Prior to 2019 in England, clinically supervised HAT had only been provided as part of the Randomised Injecting Opiate Treatment Trial (RIOTT) in 2010 (Strang et al., 2010). Despite a robust international evidence base for the social and health benefits of HAT (Haasen et al., 2007; March, Oviedo-Joekes, Perea-Milla, & Carrasco, 2006; Oviedo-Joekes et al., 2009; Perneger, Giner, del Rio, & Mino, 1998; Strang et al., 2010; van den Brink et al., 2003) and strong results from RIOTT indicating improved outcomes for ‘treatment refractory’ people (i.e. people who have not benefitted from the standard treatment offer), RIOTT did not continue beyond a trial basis. In considering possible reasons for RIOTT discontinuation, Strang et al (2015) drew on concerns about HAT noted in the international literature, such as: 1. public safety and security concerns (concentration of crime in the local area, diversion of medicinal heroin); 2. intervention expense (costs of pharmaceutical product, staff and facilities for supervised consumption); 3. diamorphophobia (anxiety around concept of heroin as medicine); and 4. patient safety (i.e. a 1 in 6000 risk of sudden onset respiratory depression) (Strang et al., 2015).

"The opening of the first UK HAT service in Middlesbrough in 2019 was therefore remarkable. The service in Middlesbrough was initially implemented as a ‘whole systems approach’ i.e. compromising partners from the health and justice sectors. The development of the Middlesbrough service is a novel example of ‘bottom-up’ policy making (i.e. pushed through by the collaboration of localised systems on limited budgets with little formal intervention from the UK government (Poulter, Moore, Crow, Ahmed, & Walker, 2022). The service closed for operation in November 2022 despite client reported benefits in relation to improved social supports and having access to an innovative treatment supporting a wide range of harm-reduction and recovery-oriented goals (Riley et al., 2023)."


Poulter, H. L., Walker, T., Ahmed, D., Moore, H. J., Riley, F., Towl, G., & Harris, M. (2023). More than just 'free heroin': Caring whilst navigating constraint in the delivery of diamorphine assisted treatment. The International journal on drug policy, 116, 104025. doi.org/10.1016/j.drugpo.2023.104025