The Strongest Evidence Yet for a Highly Controversial Addiction Treatment

As overdose deaths break records year-after-year in the U.S., a group of researchers has looked around the world for new treatment options to try and landed on a counterintuitive method. A new comprehensive report concludes that it’s time for Americans to earnestly pilot and study “heroin-assisted treatment,” a controversial approach that involves patients who are severely addicted to the drug injecting medical-grade heroin in a supervised setting.    

Motivated by the urgency of the country’s overdose crisis that killed more than 70,000 people in 2017, driven mainly by potent fentanyl analogues, researchers at the RAND Corporation, a California-based think tank, spent a year studying the medical literature and interviewing stakeholders in six other countries, along with American communities plagued by overdoses. The report also outlines the evidence for supervised-consumption sites, another harm-reduction intervention popular across Canada and Europe.

Studies in countries that use heroin-assisted treatment and supervised consumption sites have found both approaches beneficial for people who have unsuccessfully tried other, less risky approaches to treatment. But the researchers acknowledge that the evidence base for supervised consumption sites could be stronger, and that there is significant legal, political, and cultural barriers standing in the way of heroin-assisted treatment’s implementation in the U.S. America has a history of prioritizing abstinence as the ultimate goal of recovery,  and prescribing people addicted to heroin, well, heroin, can be seen as a big leap.

In heroin-assisted treatment, patients go to a clinic two to three times per day to receive injections of medical-grade heroin, otherwise known as diacetylmorphine, an opioid-receptor agonist. The treatment is typically reserved for an older population that has repeatedly tried other treatments to no avail. “This isn’t legalizing heroin or just giving it away,” says Beau Kilmer, the lead author of the 93-page report. “These are people who have been using for quite some time and they’ve tried other treatments and are still injecting. The big takeaway from the research is that this approach stabilizes their lives.”

Prescribing patients injectable heroin naturally raises eyebrows in the U.S., where methadone and buprenorphine remain difficult to obtain. Since heroin is currently a Schedule I substance, it is illegal for doctors to prescribe under any circumstances. But under the Controlled Substances Act, RAND researchers note, it can be used to conduct clinical research.

Health Canada, the government’s public-health agency, eased restrictions on heroin so it could be studied and prescribed in clinics. But Oviedo-Joekes says prescription heroin is still expensive because it must be imported from labs in Europe. As a workaround, Canadian clinics are now offering hydromorphone, a short-acting opioid typically prescribed for pain that offers users a similar euphoria as heroin when injected. A 2016 randomized trial compared the two drugs head-to-head and found patients faired equally well on either one.

Unlike diacetylmorphine, hydromorphone is a Schedule II drug that American doctors are legally allowed to prescribe. “We could roll out injectable hydromorphone treatment much faster because the legal hurdles are far lower,” says Leo Beletsky, professor of law and health sciences at Northeastern University. “But we can’t do that with heroin. We’re losing nearly 200 people each day and must act fast.”

Dan Ciccarone, who leads the Heroin In Transition research team at the University of California San Francisco, argues that the U.S. at least needs to rapidly scale-up the use of medications like methadone and buprenorphine, which only a select group of doctors are legally allowed to prescribe. As for heroin as a treatment option, he noted that the age groups in heroin-assisted treatment trials abroad skews older, even though the current heroin and fentanyl epidemics are much worse in younger age groups. “Few studies on agonist substitution are specifically done with youth,” he says.

It seems unlikely that prescribing heroin to America’s young, addicted people would ever fly. But experts all agree that one way or the other, they need saving.

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