If there has not been meaningful public deliberation about proposals, we believe their proponents can not claim that they are ethical trials in a public sense. This emergence of a pluralism of approaches to heroin problems brings with it scientific difficulties. As more and more treatments are trialled, we increase the difficulty and the cost of designing studies that can determine which collection or combinations of treatments are better than others. This does not negate the value of small trials, but it does raise the question of the relationship between trials and evaluation of treatments as a whole. The diversity of treatments and trials is wide, ranging from uncontrolled small case series through modest-sized randomised trials to modest treatment programs.
Many trials are of short duration, whereas the problem of addiction often occurs over many years.
Thus, deciding when to measure outcomes becomes an important issue. Trials risk being irrelevant to the real world of addiction if they ask questions or evaluate outcomes relevant to the short term only. Or, if we consider addiction to be a chronic relapsing condition, we might perhaps model trials for heroin addiction on those for treating diseases such as epilepsy or diabetes. Moreover, we must never forget that there can be a vast gulf between efficacy demonstrated in clinical trials and meaningful control of a public health problem. The new pluralism in treatments for heroin addiction is fragmented and uncoordinated, with no particular strategic direction.