How Prescription Heroin Can Help Addicts

Canada has lifted its ban on prescription heroin. Should the United States follow suit?
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Canada lifted a ban on prescription heroin last week, opening the door for the widespread use of a controversial treatment for long-time heroin addicts. Politicians in the United States — which has seen similarly rising rates of heroin use and overdoses as Canada — are watching closely to see the impacts of this new allowance, and whether it might be a formula to follow.

So-called heroin-assisted treatment is meant for people who have been using street heroin for several years and for whom more conventional therapies, such as methadone treatment, has failed multiple times. Proponents argue it’s the only program that can be effective for long-entrenched heroin users.

“There’s a small, but significant, group of patients that are simply not going to be attracted into care with the standard treatment,” says Scott MacDonald, the lead physician at Providence Crosstown Clinic,the only clinic in Canada that currently provides heroin-assisted treatment. “I don’t think we can turn our backs on any safe, effective, cost-effective options.”

Canada’s Conservative Party generally disapproves, with the party health spokesman telling the Washington Post, “Our policy is to take heroin out of the hands of addicts and not put it in their arms.”

“There’s a small, but significant, group of patients that are simply not going to be attracted into care with the standard treatment.”

As part of their treatment, patients come to Providence Crosstown Clinic up to three times per day to get an injection of pharmaceutical-grade heroin (scientific name: diacetylmorphine), which the clinic sources from a pharmaceutical company in Switzerland. Crosstown Clinic’s patients are very low-income and use the service for free. The program costs about $21,000 per patient, per year, the New York Times reports. One study estimated that a person with severe, untreated opioid use disorder costs about $35,000 in public funds a year, when factoring in emergency-room visits, court, and jail time.

The idea behind heroin-assisted treatment is that, because patients are guaranteed the “fix” they need in order to avoid withdrawal, they’ll stop committing crimes to support their addiction. They may even get the headspace they need to go back to school or hold a job. Crosstown Clinic provides counseling to support such moves.

In addition, because the diacetylmorphine injections are pure and they happen in the clinic, they’re supposed to prevent people from overdosing and dying in the streets. Street heroin may be cut with deadlier chemicals, such as fentanyl and carfentanil, that buyers are unaware of.

Clinical trials run at Crosstown Clinic and in Europe support the idea that prescription heroin works as advertised. (In addition to Crosstown, which has hosted short trials of heroin-assisted treatment since 2005, prescription heroin has been integrated into the health-care system in Denmark, Germany, the Netherlands, and Switzerland.) One 2009 trial at Crosstown found that, among people who had failed methadone therapy before, those who received heroin-assisted treatment were significantly less likely to use illicit drugs and to commit crimes than those who were given yet another round of methadone. But methadone seemed to be the safer option. None of the methadone patients had serious medical problems related to their treatment, while 10 of the 115 heroin-assisted treatment patients overdosed during the clinical trial and had to be resuscitated with naloxone. Seven of the 10 later reported they had taken another drug, such as benzodiazepines or cocaine, before coming in for their shot.

In 2011, a systematic review of previous studies found similar results to the 2009 Crosstown trial. Those who had failed methadone therapy and were subsequently treated with prescription heroin were more likely to stick to the treatment program, less likely to use street drugs, and committed fewer crimes. Heroin treatment was, however, a bit more dangerous than methadone: Users were more likely to overdose and experience other medical emergencies.

MacDonald hopes that, with time, the treatment method will wean some of his patients off heroin completely. “A third to one half may be able to step down to less intensive treatment,” he says. The rest may need it for much longer.

Meanwhile, there has been budding interest in the U.S. in prescription heroin. In June, MacDonald testified before the Senate Committee on Homeland Security. Canada’s Globe and Mail poked fun at the event, reporting that senators “appeared to struggle with the concept” of heroin treatment, but MacDonald had only good things to report. “The senators were just interested in hearing options,” he says. “This approach may be controversial, but when you’re facing a crisis, you need to look outside the box.” In addition, he has given a tour of Crosstown to the mayor of Ithaca, New York; the mayor of Seattle is visiting soon.

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