In heroin-assisted treatment, patients go to a clinic two to three times per 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 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 to other treatments like methadone, RAND found the injectable option consistently reduced illicit-drug use and improved treatment retention, all the while improving physical and mental health. RAND wrote in one of the key insights of their 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 the lead author of 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 prescription heroin costs more than conventional treatments, but it has 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.
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