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U.S. Pat. 47,000 opioid-related overdose deaths in 2017. Driving the surge are potent, cheap synthetics like fentanyl. Naloxone trainings to upping treatment resources.
What is the point of departure for a pilot approach to the US: offering pharmaceutical-grade heroin – yes, heroin – as a form of long-term treatment for heroin users who haven 't had success with other treatments. It's happening in several European countries and Canada. But these would be controversial interventions, says Beau Kilmer, who co-directs RAND's drug policy research center.
But there are about 50,000 deaths and fentanyl deaths near 30,000, which are grounded in the research and grounded in the experiences of other countries. "
Here's how programs offer heroin, or heroin-assisted treatment (HAT), 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 they have a legal source of heroin, they are 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 the most effective treatments in different ways to address cravings and symptoms. But these first-line treatments do not work for some longtime opioid users. In Canada's main study of prescription heroin, eligible patients had already tried quitting heroin at 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.
Heroin-assisted treatment is different from the concept of supervised consumption sites, where patients bring in their own illicit drugs and then inject them while medical staff are present, ready to answer in case of an overdose. These are increasingly debated in the U.S. as a dozen cities consider them.
Kilmer says heroin has been researched with more rigorous methods. Several randomized controlled trials in Canada, the United Kingdom and the Netherlands. They were more likely to stay in a hospital, and they were less likely to revert to using illicit heroin. Evidence suggests that methadone in reducing criminal activity and improving patients' physical and mental health.
Chinazo Cunningham, an addiction specialist at the Albert Einstein College of Medicine and the Montefiore Medical Center in the Bronx, are alternative approaches, but they are more imperative in the U.S. to focus on what she sees as the most pressing issue right now:
As it stands, a vast majority, "We have treatment that works, it just needs to be done in a way that is accessible to people."
"It's hard to imagine heroin-assisted treatment because I think it's 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 prescribing heroin is new to many and what is skeptical about 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.
And there's a big legal obstacle. Heroin is a strictly regulated Schedule 1 drug which means can not prescribe it. It is legal to conduct research on Schedule 1 Drugs, but it is a medical process, it is a process that would require approvals from several government agencies including the DEA. There are no human trials currently underway for heroin, according to the National Institute on Drug Abuse. Still, the RAND report says it could offer insight into the results abroad.
The report says, "Communities might consider studying a Schedule 2 opioid, hydromorphone, which is used for pain in the U.S." There would be fewer hurdles to setting up a pilot program. A study in Vancouver offers injectable hydromorphone to patients.
Still, there are a few addiction specialists in the United States. In New York, Cunningham's colleague at the Albert Einstein College of Medicine, dr. Aaron Fox says it's open to it. In fact, he's spending the next part of next year on leave to study heroin in other countries, with hopes of "figuring out how to do a pilot" back in the U.S.
He says he does not like it as a silver bullet, but it does not treat other diseases as well.
"People need additional options for something like cancer are other treatments, "Fox says. When people are unable to stop or cut down on their heroin use when enrolled on methadone or buprenorphine, we need other options for people. "
What fuels him seeing patients, like a recent woman, who just has not had success with other treatments. He recalls wanting to return to the methadone program she had been in before, but she was struggling and decompensated.
"I'm not going to say, 'I tried my best, that's it," he says. "Why not use that in the U.S.?"
Elana Gordon ( @elana_gordon ) is a health reporter and a 2018-2019 Knight Science Journalism Fellow at MIT.