The U.S. should start seriously considering offering drug users prescription-grade heroin to reduce their risk of using far more dangerous drugs off the street, according to a first-of-its-kind analysis of existing research and data. But that sort of approach faces serious roadblocks. In an analysis released Thursday, experts with Rand Corporation, a nonpartisan public policy think tank based in Santa Monica, California, found that it’s worth taking another look at prescription heroin, especially considering an alarming 70,000 people died of drug overdoses nationwide in 2017, due, in part, to ultra-potent, hard-to-detect synthetic opioids like fentanyl. With prescription heroin, drug users would have access to supervised facilities where clinical professionals would oversee quality-controlled doses of the drug.
The researchers’ recommendation, however, would take lots of politicking — and might not ever pan out. It’s already hard enough to get a supervised injection site, a safe place where people can use their own drugs under medical supervision, off the ground in liberal-leaning cities like New York City, San Francisco, and Seattle. In short, the researchers conclude that America should launch a pilot program to “offer a legal, quality-controlled, free, or low cost pharmaceutical opioid as a replacement for expensive illicit market opioids of unknown potency whose acquisition may lead users to commit crime or potentially put themselves in dangerous situations.” Unlike supervised injection sites, which the researchers write still lack quality supporting research, countries around the world have already implemented heroin-assisted treatment with measurable success. “This is not a silver bullet or first-line treatment. But there is evidence that it helps stabilize the lives of some people who use heroin,” Beau Kilmer, leader of the research project and co-director of the RAND Drug Policy Research Center, said in a statement. The researchers note that until the Harrison Act of 1914, which regulated opiates and cocaine, heroin maintenance treatment existed in the U.S. Still, officials have had enough problems ensuring widespread access to approved, legal forms of medication-assisted addiction treatment, like buprenorphine, methadone, and naltrexone.
The evidence behind prescription heroin
Several countries — the United Kingdom, the Netherlands, and Canada among them — offer some form of prescription heroin treatment. There, treatment first directs patients toward less controversial drugs like methadone and buprenorphine before offering a more extreme measure, like heroin. And that’s usually only after a patient has tried to quit heroin several times to no avail. Even with the option of heroin, the more traditional medications have remained more popular.
In Switzerland, for example, 22 heroin-assisted treatment facilities have a capacity to treat 1,600 patients, according to the Rand analysis. More than 10 times as many people still use prescription methadone or buprenorphine instead. That alone contests a common critique of facilitating innovative help for drug users: enabling drug users and therefore, driving more dangerous drug use.
In Swiss facilities and elsewhere, only professionals inside special clinics can administer heroin in regular and measured doses. That process keeps people away from illicit, street-sourced drugs and can succeed in reducing crime.
What would need to happen
To allow for prescription heroin in the U.S., the Drug Enforcement Administration or Congress would have to change heroin’s classification under federal law. Currently, heroin is a Schedule I drug, along with marijuana and ecstasy, which means a drug doesn't have any accepted medical use. Heroin would have to be changed to a Schedule II substance, like its opiate counterparts OxyContin and fentanyl, for physicians to prescribe the drug. And“scheduling is just one barrier,” as the researchers note in the Rand analysis. Researchers also found in interviews with “key informants” — policy professionals, service providers and drug users — that practical, legal, and community resistance exists to prescription heroin. Other innovative harm-reduction methods, like syringe exchanges and safe injection sites — which also remain illegal under federal law — have already faced similar opposition. Universities, however, could apply for research exemptions to study the effectiveness of a Schedule I substance via randomized controlled trials, which could create a small-scale pilot program for heroin-assisted treatment, according to the researchers. Depending on the findings of the studies, the U.S. could then consider changing its federal laws to accomodate and scale its own heroin-assisted treatment program while assessing risks and concerns unique to their communities.
Cover image: In this Oct. 22, 2018 file photo, a fentanyl user holds a needle near Kensington and Cambria in Philadelphia. (David Maialetti/The Philadelphia Inquirer via AP, File)