A call to the US to pilot a prescription heroin program: Shots


In several European countries and Canada, patients with long-term opioid dependence are prescribed pharmaceutical grade heroin that they inject at clinics such as the Patrida Medical Clinic in Berlin. Some addiction experts want to pilot similar programs in the US.

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alliance of image / alliance of image via Getty Image

In several European countries and Canada, patients with long-term opioid dependence are prescribed pharmaceutical grade heroin that they inject at clinics such as the Patrida Medical Clinic in Berlin. Some addiction experts want to pilot similar programs in the US.

alliance of image / alliance of image via Getty Image

The drug crisis in the US does not seem to be diminishing. The nation suffered a 47,000 death from opiate-related overdoses in 2017. Boosting the outbreak are potent and inexpensive synthetic drugs such as fentanyl. They have spread to illicit drug supply and in response, communities have attempted a range of interventions, ranging from naloxone training to increased treatment resources.

But a new analysis of the policy think tank, the Rand Corporation, concludes that it is time to pilot an approach outside the US: offering pharmaceutical grade heroin – yes, heroin – as a form of treatment for long-time heroin users who do not were successful with other treatments. It is already happening in several European countries and in Canada. But that would challenge culture, law and practice in the United States.

"These are controversial interventions," says lead author Beau Kilmer, who co-directs RAND's drug policy research center. "There are some people who do not even want to talk about it. But considering where we are with about 50,000 opioid deaths and about 30,000 fentanyl deaths, it is important that we have discussions about these interventions that are grounded in research and grounded in the experiences of other countries ".

See how programs that offer prescription heroin or heroin-assisted treatment (HAT) work. Patients usually receive a regular dose of pharmaceutical grade heroin – also known as diacetylmorphine or diamorphine – and inject it under medical supervision into a designated clinic. The idea is that if people have a legal source of heroin, they will be less likely to overdose of toxic drugs, will spend less time and energy trying to get their next dose, and instead will be able to focus on the underlying factors of your addiction. .

"This is just another treatment that can help stabilize lives," says Kilmer.

It is not for everyone. Medications like methadone, buprenorphine and naltrexone are highly effective treatments that work in different ways to deal with the desires and symptoms of withdrawal or block the effects of drugs. But these first-line treatments do not work for some long-standing opioid users. In Canada's main heroin prescription study, eligible patients had already tried to quit heroin 11 times on average.

The prescription of heroin as a form of maintenance therapy dates back to the early 1920s in the UK and accelerated in the 1990s in other parts of Europe. (It was even one thing in the US before the early 20th century federal drug laws).

Heroin-assisted treatment is different from the concept of supervised drug use, where patients bring their own illicit drugs and inject them while medical staff are present, ready to respond in the event of an overdose. These are increasingly debated in the US, since at least a dozen cities consider them.

Kilmer says heroin prescription 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 the RAND analysis. They were more likely to stay on treatment compared to those who took methadone, and they were less likely to re-use illicit heroin. Evidence also suggests that prescription heroin may be more effective than methadone in reducing criminal activity and improving the physical and mental health of patients.

For Dr. Chinazo Cunningham, a dependency specialist at Albert Einstein College of Medicine and at Montefiore Medical Center in the Bronx, alternative approaches are important, but she thinks it is more imperative in the US to focus on what she sees as the most pressing issue at the time. "We have treatment that works, we just need to provide it in an accessible way to people," she says.

As it stands, the vast majority of people who could benefit from top-line opioid use disorders are not getting it, a problem that is even driving a black market for treatment.

"It's hard for me to imagine heroin-assisted treatment because I think right now talking about getting more conventional treatment like methadone, buprenorphine and naltrexone for people, there's already a lot of stigma around that," says Cunningham.

As part of the review, RAND conducted focus groups and interviews in several counties in New Hampshire and Ohio, hard hit by the overdose crisis. The idea of ​​heroin prescription was new to many and was met with skepticism as to its acceptance by health professionals, local leaders, and those in treatment. People fear that heroin-assisted treatment "allows the use of drugs" and faces resistance from the community.

And there is a great legal obstacle. Heroin is a strictly regulated drug, which means doctors can not prescribe. It is legal to conduct drug research on Table 1, but, as seen in medical marijuana research, it is a difficult process that would require approvals from various government agencies, including the DEA. There are no ongoing human trials for heroin, according to the National Institute on Drug Abuse. Still, the RAND report says that a pilot program could provide insight into whether results abroad could be translated by the United States.

The report says that, alternatively, communities may consider the study of an opiate of Annex 2, hydromorphone, which is used for pain in the USA. There would be fewer obstacles to the creation of a pilot program. A study in Vancouver found that it is as effective as prescription heroin, and now at least seven sites in Canada offer hydromorphone injectable to patients.

Still, there seems to be some interest from at least some US addiction experts. In New York, Cunningham's colleague at Albert Einstein School of Medicine, Dr. Aaron Fox, says he is open to it. In fact, he is spending the early part of next year on leave to study heroin prescribed in other countries, hoping to "figure out how to make a pilot" in the US.

He says he does not see this as a silver bullet, but often this is not how treatments work for other diseases.

"If people do not respond to treatment, there are other treatments," says Fox. "If people are not able to stop or reduce heroin use when they enroll in methadone or buprenorphine, we need other options for people. "

What feeds him is seeing patients, like a recent woman, who simply was not having success with other treatments. He remembers wanting her to go back to the methadone program she'd been in before, but she was struggling and unbalanced. He did not want to give up.

"I will not say" I tried my best, that's it ", when those other tools proved effective in other countries," he says. "Why not use this in the US?"

Elana Gordon (@elana_gordon) is a health reporter and Knight Science Journalism fellowship 2018-2019 at MIT.


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