Older users require new rules

The success of medical heroin provision is no longer up for debate. Since its introduction in 2007, the provision has been so successful that participants are aging much more than anticipated, a development which nobody had prepared for. While other geriatric patients receive entire strips of benzos delivered to their homes, a similar patient must independently visit the GGD twice a day to receive their medication. It’s high time for a change.

Since the introduction of the Medical Supplementation Unit (MSU) in 2007, medical heroin has been viewed as a medicine. However, participants are still treated as drug users, addicts, and junkies – and not as patients. Patients that, as they age, increasingly experience other complaints or illnesses which can affect anyone, regardless of drug use.

But how do you deal with someone dependent on medical heroin who is also experiencing early-stage dementia? How do you prevent someone from becoming ill due to drug withdrawal when they can no longer articulate their needs? What do you do when someone becomes so immobile that they cannot independently reach the GGD? Or worse, what if someone literally cannot remember the way to the GGD?

Lars* is in his 70s and has been benefiting from heroin provision for four years. It has allowed him to avoid spending his entire day on the streets, stay out of trouble, and keep his usage under control. Most importantly, it has given him a peaceful life with routine and stability. Unfortunately, his routine was recently disrupted by early-stage dementia. Consequently, he was no longer able to live independently and had to move to a care facility—a significant change causing much distress. The autopilot that previously made his condition seem “mild” is now failing. Lars will have to relearn how to find his way to the GGD twice a day. And that has proven to be a challenge.


Lars’ day now revolves solely around his two visits to the GGD. After the morning visit, he is so exhausted from the mental and physical exertion that he needs to sleep to gather enough strength to return in the afternoon. There is hardly any time left for him to enjoy his old age.

The social worker at the GGD printed a map with directions, but sometimes that’s not enough for Lars to find his way. One day, we coincidentally found him halfway there and took him on the back of a bike to the MDHG. We arranged for a volunteer to accompany him home and ensured that a familiar member, who also makes use of the provision, would pick him up in the afternoon to go to the GGD. All in the hope that after several walks back and forth, he would remember the route.

Lars is an example of a situation for which we are not adequately prepared. The population of heroin users in Europe remains stable, but their healthcare and support needs are becoming increasingly complex. After all, this is the first generation of aging heroin users. It is high time for clients of the MSU to be allowed to smoke their heroin at home. A few years ago, it was unthinkable for a large group of people to take methadone home for several consecutive days. Because “what if that methadone ends up on the black market?” Yet, practice shows that people generally handle their medication in a trustworthy way.

It became evident in Switzerland that this approach is feasible when, in response to COVID measures, they successfully introduced a take-home HAT (Heroin Assisted Treatment) using DAM tablets (diacetylmorphine). Patients had to have participated continuously in heroin provision for at least six months and be in a stable health and social condition. Urine tests had to be negative for all drugs except heroin or DAM. Additionally, the person had to have biweekly contact with the treating physician to monitor adherence to therapy. If these conditions were met, medication could be dispensed for up to 7 days. And what was the outcome? No evidence was found of abuse of home-doses, nor was there any indication that the substances were being resold.

Users of the MSU also want a trial of home-doses, as Spuit 11 already wrote in the summer of 2022. A survey by the GGD’s Client Advisory Board found that the vast majority of people would like to make use of a take-home policy. Either way, heroin provision will require more customized solutions as the target group’s healthcare needs change. Therefore, it is necessary to investigate alternative solutions, such as taking medication home, using special transportation more often, and developing a plan for dealing with, for example, demented or palliative patients. Some call this “out-of-the-box” thinking, but it’s really just common sense.

*Lars is not really named Lars, but we do know who he is.

By: Leonie Brendel