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Researchers and policymakers from around the world met at a symposium in Vancouver earlier this month to discuss expanding a scientifically promising—yet politically controversial—form of treatment for opioid use disorder. It's called "supervised injectable opioid assisted treatment," otherwise known as heroin-assisted treatment. In its two decades of existence, it appears that not one patient undergoing heroin-assisted treatment has died from an overdose.
How's that possible? The treatment works a lot like it sounds: Two to three times a day, people with severe opioid problems—who have struggled for years trying to get better using other approaches, but to no avail—walk into professionally-run medical clinics and inject heroin (diacetylmorphine). Instead of gambling on the street with a supply poisoned with uber-potent fentanyl, doctors and nurses administer pharmaceutical-grade doses. If there's an overdose or seizure, a team of professionals is on standby to react. In effect, the heroin user is protected from the ills of an illicit marketplace, such as fatal overdoses, committing petty crime to get a fix or exposure to blood-borne diseases.
Perhaps even more profound for the user is that she finds herself in a compassionate medical setting that is not out to punish her for struggling with a complex illness. "Heroin-assisted treatment is just like any other medical treatment," says Eugenia Oviedo-Joekes, an associate professor at the School of Population and Public Health at the University of British Columbia, who is among the scientists who communicated decades of favorable research behind the approach to policymakers during an invite-only session. "We don't just see the drug, which is just one piece to the puzzle. We see the person, and we're treating them and their pain."
Tragically, no major American institutions were in attendance at the University of British Columbia's international symposium. However, one lone American doctor was there: Andrew Seaman, an assistant professor of medicine at Oregon Health & Science University. "Coming from an American perspective, heroin-assisted treatment is a radical idea," he says. "So it was nice to be in Vancouver and hear people who've totally normalized what should be a standard of care." Seaman says that heroin-assisted treatment is simply evidenced-based medicine, and what makes it so exceptional is not the approach itself, but rather the stigma and politics surrounding it.
American doctors like Seaman are in short supply. Somehow our deadly, relentless overdose crisis, killing an estimated 91 people every day, has yet to spark the interest of our politicians and policymakers—despite the fact that it's a novel approach that two decades of painstaking research shows can stabilize the lives of even the most hard to reach, at-risk heroin users. Legislators remain entangled in an American "morality" that blinds them to harm-reduction interventions like heroin-assisted treatment.
Meanwhile, the death toll rises unabated from a dangerous heroin supply contaminated with illicitly manufactured fentanyl. The need for safe heroin in America has never been greater. It's time for our policymakers to see beyond themselves and look around the world at how a responsible, rational and humane response to an overdose crisis can stop a disaster in its tracks.
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Take Switzerland. During the '90s, the country looked a lot like America does now. In a population of about 7 million, some 30,000 people were addicted to drugs, the highest in Western Europe at the time. Fatal overdoses were surging, as were drug-related crimes and homelessness; HIV and Hepatitis C outbreaks were constant. Then, the Swiss government rolled out the world's first ever heroin-assisted treatment program in 1994.
Overdoses plummeted by 50 percent from 1994 to 2000, according to an evaluation of the program by the Addiction Research Institute housed in Stockholm University. "The low mortality rate is all the more noteworthy as heroin-assisted treatment in Switzerland included only refractory opioid addicts with existing severe somatic and/or mental problems," the study's authors conclude.
On top of saving lives from fatal overdoses, Switzerland's heroin treatment also caused a significant drop in crime, which freed up funds previously tied to criminal justice. There were also substantial improvements in overall health and well-being, because the clinics doubled as a bridge to other social services.
Countries keenly watched the Swiss model as they sought solutions to their own public health problems stemming from drug use. Within 20 years of Switzerland's bold move, The Netherlands, United Kingdom, Germany, Spain, Denmark, Belgium, Canada and Luxembourg had all tested the feasibility and efficacy of the model in their own countries —and had similarly positive results. But America has yet to follow the footsteps of Western Europe and Canada. It's like we've become too comfortable living in the dark ages of addiction treatment, too at home in a country where sympathetic, bipartisan rhetoric in the form of do-nothing awareness campaigns and task forces headed by criminal prosecutors prevails over action backed by evidence.
Bluster and misinformation permeate American drug treatment and policy. Politics not only stunts progress, it's actually killing us. Earlier in May, for example, Health Secretary Tom Price went on a "listening tour" to learn about the opioid crisis. While visiting West Virginia—a state with so many overdoses that a burial-assistance program for needy families ran out of money—Price called medication-assisted treatment, an approach that uses buprenorphine and methadone (not heroin), which research also shows reduces mortality rates by more than 50 percent, as "just substituting one addiction for another."
Scott MacDonald, lead physician at Crosstown, a clinic that provides heroin to its patients in Vancouver, says that he tells conservatives all the time that heroin-assisted treatment is a solution to so-called "public disorder." "There's less crime, less societal costs," he says. "Everyone benefits."
But Trump's administration is frustratingly immune to even-handed arguments backed by research. Price, a physician and longstanding member of the American Medical Association, curiously prefers not-so-scientific "faith-based" treatments, which leave patients at twice the risk of dying of a fatal overdose upon leaving than those who are treated with medications.
Price's opinion happens to be in tune with America's mainstream approach to addiction treatment. So-called spiritual approaches to treating addiction—like the 12 Steps, which are actually self-help groups, not treatment—pervade America's system. As someone who was treated for a heroin addiction five years ago, I can assure you I've seen The Steps on the walls of every rehab I've been to. To be sure, there have been recent advances at the federal level in favor of medication-assisted treatment, like from Vivek Murthy, our former surgeon general, who called out Price for his misinformed opinion.
Oviedo-Joekes, who has been an investigator on three heroin trials, says dealing with doctors like Price, who cling to outdated knowledge, can sometimes feel like dealing with people in the anti-vaxxer movement. "We have 80 percent retention rates at six months," she says, referring to the number of participants that remain in treatment. "Programs that don't use opioid medications have closer to 30 percent," a huge drop out rate. "Our approach is a no-brainer."
Had Secretary Price attended this month's symposium, he would have also had the opportunity to meet with real people who are undergoing heroin-assisted treatment. He would have heard from the folks at the Canadian Association of People who Use Drugs, a group of drug users who fearlessly organize on behalf of themselves to make their voices heard. Drugs take a backseat to their humanity during such conversations. Lame stereotypes about being lazy and selfish invariably melt when confronted with people, who like everyone else, are simply doing their best to get by each day.
"Folks need to be cured so they can be productive members of society and realize their dreams," Price said on his listening tour. Thing is, we can't achieve our dreams if we're dead.
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