· · · December 6, 201812:36 AM ET
Driving the surge are potent, cheap synthetics like fentanyl that have spread into the illicit drug supply. In response, communities have been trying a range of interventions, from increasing the availability of the antidote naloxone to upping treatment resources.
But an analysis released Thursday by the Rand Corporation, a policy think tank, concludes it's time to pilot an approach from outside the U.S.: offering pharmaceutical-grade heroin — yes, heroin — as a form of treatment for longtime heroin users who haven't had success with other treatments. It's already happening in several European countries and Canada. But prescribing heroin would challenge culture, laws and practice in the U.S.
"These are controversial interventions," says lead author Beau Kilmer, who co-directs RAND's drug policy research center. "There are some people that don't even want to have conversations about this. But given where we are with opioid deaths near 50,000 and fentanyl deaths near 30,000, it's important that we have discussions about these interventions that are grounded in the research and grounded in the experiences of other countries."
Here's how programs that offer prescription heroin, or heroin-assisted treatment, work. Patients typically get a regular, measured dose of pharmaceutical-grade heroin — also known as diacetylmorphine or diamorphine — and inject it under close medical supervision inside a designated clinic. The idea is if people have a legal source of heroin, they'll be less likely to overdose on tainted street drugs, spend less time and energy trying to get their next fix, and instead be able to focus on the underlying drivers of their addiction.
"This is just another treatment that could help stabilize lives,"says Kilmer.
It's not meant for everyone. Medications like methadone, buprenorphine and naltrexone are highly effective treatments that function in different ways to address cravings and withdrawal symptoms or block the effects of drugs. But these first-line treatments don't work for some longtime opioid users. In Canada's main study of prescription heroin, eligible patients had already tried quitting heroin an average of 11 times.
Prescription heroin as a form of maintenance therapy dates back to the early 1920s in the UK, and revved up in the 1990s in other parts of Europe. (It was even allowed in the U.S. before the sweeping federal drug laws of the early 20th century.)
Heroin-assisted treatment is different from the concept of supervised consumption sites, where patients bring their own illicit drugs and then inject them while medical staff are present, ready to respond in case of an overdose. These are increasingly debated in the U.S. as at least a dozen cities consider them.
Kilmer says prescription heroin has been researched with more rigorous methods. Several randomized controlled trials in Canada, the United Kingdom and the Netherlands found that people addicted to heroin benefited from the approach, according to RAND's analysis. They were more likely to stay in treatment compared with those who took methadone, and they were less likely to revert to using illicit heroin. Evidence also suggests that prescription heroin may be more effective than methadone in reducing criminal activity and improving patients' physical and mental health.
For Dr. Chinazo Cunningham, an addiction specialist at Albert Einstein College of Medicine and Montefiore Medical Center in the Bronx, alternative approaches are important, but she thinks it's more imperative in the U.S. to focus on what she sees as the most pressing issue right now: "We have treatment that works, we just need to provide it in a way that is accessible to people," she says.
As it stands, a vast majority of people who could benefit from first line treatments for opioid use disorder aren't getting it, a problem that's even driving a black market for treatment.
"It's hard for me to imagine heroin-assisted treatment because I think right now even talking about getting more mainstream treatment like methadone, buprenorphine and naltrexone to people, there's already so much stigma around it," says Cunningham.
As part of the analysis, RAND conducted focus groups and interviews in several New Hampshire and Ohio counties hit hard by the overdose crisis. The idea of prescription heroin was new to many and was met with skepticism over its acceptability from health professionals, local leaders, and those in treatment. People worried that heroin-assisted treatment "would enable drug use" and face community resistance.
Elana Gordon is a health reporter and a 2018-2019 Knight Science Journalism Fellow at MIT. You can follow her on Twitter: @elana_gordon.
TO CONTINUE READING:https://www.npr.org/sections/health-shots/2018/12/06/673986164/is-america-read