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The drug crisis in the United States does not seem to have gotten tired. In 2017, the nation experienced a destruction of 47,000 deaths from opiate-related overdoses. Leading the wave are powerful and inexpensive synthetics like fentanyl. They have spread to illicit drugs and in response the communities have tried a series of interventions, from an increase in naloxone training to treatment resources.
But a new analysis of the reflection group on politics, the Rand Corporation, concludes that it is time to pilot an approach outside the United States: to offer pharmaceutical grade heroin – yes, heroin – as a form of treatment for heroin users for a long time they have not been successful with other treatments. It is already happening in several European countries and in Canada. But it would question the culture, laws and practice in the United States.
"These are controversial interventions," says lead author Beau Kilmer, who co-directs the research center on the anti-drug policy of the RAND. "There are some people who do not even want to have conversations about this, but given where we are with opioid deaths close to 50,000 dead and fentanyl near 30,000, it is important that we discuss these interventions that are grounded in research and grounded in the experiences of others. countries ".
Here's how the programs that offer prescription heroin or treatment with heroin (HAT) work. Patients typically receive a regular and measured dose of pharmaceutical grade heroin – also known as diacetylmorphine or diamorphine – and inject it under close medical supervision within a designated clinic. The idea is that if people have a legal source of heroin, they will be less likely to overdose with contaminated street drugs, spend less time and energy trying to get their next solution, and instead be able to focus on drivers at the base of their dependence.
"This is just another treatment that could help stabilize life," says Kilmer.
It is not meant for everyone. Drugs such as methadone, buprenorphine and naltrexone are highly effective treatments that work in different ways to address withdrawal desires and symptoms or block the effects of drugs. But these first-line treatments do not work for some long-term opiate users. In the leading Canadian prescription heroine study, eligible patients had already tried to stop heroin an average of 11 times.
Prescription heroin as a form of maintenance therapy dates back to the early 1920s in the United Kingdom and in the 1990s in other parts of Europe. (It was even one thing in the United States before the vast federal drug laws of the early 20th century.)
Treatment with heroin is different from the concept of supervised consumer sites, where patients bring their illicit drugs and then inject them while medical personnel are present, ready to respond in case of overdose. These are increasingly debated in the United States, as at least a dozen or so cities consider them.
Kilmer says that prescription heroin has been studied with more rigorous methods. Several randomized controlled trials conducted in Canada, the United Kingdom and the Netherlands revealed that people dependent on heroin benefited from the approach, according to the RAND analysis. They were more likely to remain on treatment than those taking methadone, and they were less likely to return to using illicit heroin. The evidence also suggests that prescription heroin may be more effective than methadone in reducing criminal activity and improving the physical and mental health of patients.
For Dr. Chinazo Cunningham, addiction specialist at the Albert Einstein College of Medicine and at the Montefiore Medical Center in the Bronx, alternative approaches are important, but you think it is more imperative in the United States to focus on what you see as the most urgent problem right now: "We have treatment that works, we just need to provide it in a way that is accessible to people," he says.
At present, the vast majority of people who could benefit from first-line treatments for opioid use disorder do not get it, a problem that is also driving a black market for treatment.
"It's hard for me to imagine a heroin treatment because I think now, even talking about getting more traditional treatments like methadone, buprenorphine and naltrexone to people, there's already so much stigma around," says Cunningham.
As part of the analysis, RAND conducted focus groups and interviews in several counties of New Hampshire and Ohio hit hard by the overdose crisis. The idea of prescription heroine was new to many and was met with skepticism about its acceptability by health professionals, local leaders and those who were being treated. People feared that the treatment with heroin "would allow the use of drugs" and tackled community resistance.
And there's a big legal obstacle. Heroin is a strictly regulated drug program, which means doctors can not prescribe it. It is legal to conduct research on the drugs of Program 1, but, as we see in medical marijuana research, it is a difficult process that would require the approval of various government agencies, including the DEA. There are no studies on man currently going on for heroin, according to the National Institute on Drug Abuse. However, the RAND report states that a pilot program could provide an insight into the fact that results abroad could translate into the United States.
The report alternatively states that communities might consider studying an Opioid of Schedule 2, hydromorphone, which is used for pain in the United States. There would be fewer obstacles in setting up a pilot program. A study in Vancouver found that it was as effective as prescription heroin, and now at least seven sites in Canada offer injectable hydromorphone to patients.
However, there seems to be some interest from some addiction specialists in the United States. In New York, Cunningham's colleague at the Albert Einstein College of Medicine, Dr. Aaron Fox, claims to be open to this. In fact, he is spending the first part of next year under license to study prescription heroin in other countries, hoping to "figure out how to pilot" in the United States.
He says he does not see it as a silver bullet, but it's often not the case that treatments also work for other diseases.
"People need additional options for something like cancer: if people do not respond to treatment, there are other treatments," says Fox. "If people are unable to stop or reduce their heroin use when they enroll in methadone or buprenorphine, we need other options for people."
What fuels it is to see patients, like a recent woman, who was not having success with other treatments. Remember that she wanted her to return to the methadone program she had been before, but she was in trouble and decompensated. He did not want to give up.
"I'm not going to say" I did my best, it's like that "when there are other tools that prove effective in other countries," he says. "Why not use it in the United States?"
Elana Gordon (@elana_gordon) is a journalist of Health and a Fellow of Journalism of the Knight of 2018-2019 at MIT.