The Strongest Evidence Yet for a Highly Controversial Addiction Treatment

When other approaches fail, the most effective way to fight a heroin addiction can be heroin itself.

A man injects heroin at a supervised-consumption site in Vancouver.
A man injects heroin at a supervised-consumption site in Vancouver. (Darryl Dyck / AP)

As overdose deaths have broken records year after year in the U.S., a group of researchers has looked around the world for new treatment options to try and has 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, which killed more than 70,000 people in 2017 and which is 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 are 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 a 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.”

In the U.S., there are two FDA-approved agonist medications for treating opioid-use disorder: methadone and buprenorphine. Experts broadly agree that these medications, considered the “gold standard” of care, are effective in reducing overdose deaths. Research has found that both medications are better at keeping people engaged in treatment than traditional abstinence-based approaches, while reducing all-cause mortality by 50 percent or more. But these drugs aren’t a good fit for everyone. Studies show that roughly 40 percent of people offered these medications continue to use illicit opioids. There have also been anecdotal reports of people addicted to potent fentanyls not finding adequate relief from far less potent opioids like methadone and buprenorphine.

That’s where prescription heroin comes into play. Double-blind, randomized controlled trials are considered the strongest way to test a drug’s effectiveness, and by analyzing 10 randomized trials comparing injectable heroin with other treatments like methadone, Rand found that the injectable option consistently reduced illicit-drug use and improved treatment retention, all while improving physical and mental health. Rand wrote in one of the key insights of its report that heroin-assisted treatment has the ability to reduce criminal activity among patients.

“The police love our model,” says Eugenia Oviedo-Joekes, a professor of public health at the University of British Columbia and one of the researchers behind North America’s first randomized prescription-heroin trial. “We provide the medicine, and then drug dealers don’t have a business.” The Vancouver Police Department has indeed come out as an unlikely ally in favor of the heroin clinic, calling addiction a health issue. Cost-benefit analyses show that prescription heroin costs more than conventional treatments, but that it has the potential for cost savings in the long run, due to the crime-reduction component.

Injectable treatments do come with their share of risks and side effects, such as overdoses and skin rashes caused by daily injections. But under medical supervision, overdoses can be reversed by naloxone, and patients can receive skin and wound care. The Rand researchers argue that for severe users, the risks of injecting illicit drugs of unknown purity on the street are far greater than injecting inside a clinic.

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 country’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 work-around, 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 that patients fared 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, a 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 at San Francisco, argues that the U.S. needs to at least 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 skew 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.