Is America Ready For Prescription Heroin?

The U.S. drug crisis does not appear to be letting up. The nation experienced a shattering 47,000 opioid-related overdose deaths in 2017.

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.

And there's a big legal obstacle. Heroin is a strictly regulated Schedule 1 drug which means doctors can't prescribe it. It is legal to conduct research on Schedule 1 drugs, but as is seen with medical marijuana research, it is a difficult 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 a pilot program could offer insight into whether the results abroad might translate stateside.

The report says as an alterantive 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 found it was as effective as prescription heroin, and now at least seven sites in Canada offer injectable hydromorphone to patients.

Still, there does appear to be some interest from at least a few addiction specialists in the U.S. In New York, Cunningham's colleague at the Albert Einstein College of Medicine, Dr. Aaron Fox, says he's open to it. In fact, he's spending the early part of next year on leave to study prescription heroin in other countries, with hopes of "figuring out how to do a pilot" back in the U.S.

He says he doesn't see it as a silver bullet, but often that's not how treatments work for other diseases, either.

"People need additional options for something like cancer. If people fail responding to treatment, there are other treatments," Fox says. "If people aren't able to stop or cut down on their heroin use when enrolled on methadone or buprenorphine, we need other options for people."

What fuels him is seeing patients, like a recent woman, who just wasn't having success with other treatments. He recalls wanting her to return to the methadone program she had been in before, but she was struggling. He didn't want to give up.

"I'm not going to say, 'I tried my best, that's it,' when there are these other tools shown to be effective in other countries," he says. "Why not use that in the U.S.?"

Elana Gordon is a health reporter and a 2018-2019 Knight Science Journalism Fellow at MIT. You can follow her on Twitter: @elana_gordon.

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