With overdose death rates continuing to climb, is it time for a realistic look at the role prescription heroin could play in combating the opioid crisis?
On the morning of Saturday, Jan. 12, police in Chico, California, responded to a mass overdose.
Eight ambulances and six fire trucks were on scene.
Chico Fire Department Division Chief Jesse Alexander later told local news outlet KHSL-TV that it was the largest mass casualty incident he had seen in years.
First responders administered naloxone, colloquially known as the “anti-overdose drug.”
At one point Alexander describes six individuals simultaneously undergoing CPR from first responders.
In total, 14 people were hospitalized, several in critical condition, and one was dead.
The likely culprit? Fentanyl.
The synthetic opioid, 100 times more powerful than morphine, and its analogues have become the most prominent driving factorTrusted Source in death rates in the United States related to opioid overdose.
In 2017, 47,000 people died from opioid-related deaths in the United States — rivaling the number of deaths from the peak of the AIDS crisisTrusted Source in 1995.
A new study published this month concludes that Americans are now more likely to die from an opioid overdose than from a car accident.
While life expectancy continues to grow in other developed countries, it’s actually declining in the United StatesTrusted Source, with drug overdose one of the main factors.
There’s no sign of the opioid crisis in the United States abating. And with no end in sight, perhaps a radical shift in policy needs to take place.
According to a new report by the Rand Corporation, a policy think tank, the answer is yes.
Heroin-assisted treatment (HAT) and supervised consumption sites (SCS) have been successfully implemented in Europe and Canada but remain legally and ethically dubious in the United States.
The theory is simple: By providing people who use opioids with clean needles and a medical-grade drug that’s used under doctor supervision, the risks of overdose, adulterated street drugs, transmitting disease, and other social risk factors are mitigated.
Additionally, users are also prescribed oral methadone (a common and effective treatment for opioid addiction) to stem cravings.
The Rand report concludes that based on how these programs have been received abroad, it would be worthwhile to pursue clinical trials for HAT and SCS here at home.
“When we talk about heroin-assisted treatment, we’re not talking about legalizing heroin and making it for sale at CVS,” Beau Kilmer, PhD, co-director of Rand’s drug policy research center and first author of the report, told Healthline.
“This is not a first-line intervention. This is for people who have tried evidence-based treatments multiple times. Many of them have been using for well over a decade, but they are still using heroin,” he said.
The benefits of HAT and SCS are myriad, according to studies published in Europe and Canada, which Kilmer and his team reviewed for their report.
Some of their key findings include:
- HAT, along with prescribed oral methadone, can offer benefits over just oral methadone.
- HAT can reduce criminal involvement by providing people with a stable source of heroin.
- HAT reduces exposure to adulterated and potentially fatal synthetic opioids, such as fentanyl.
“It was more likely to reduce their use of street-sourced heroin, and for a lot of individuals it ended up kind of helping stabilize their lives,” Kilmer said.
“For people who have been using heroin for over a decade, a lot of them spend a lot of their time either under the influence and/or trying to get funds — sometimes that can involve criminal activity, sometimes that can involve putting yourself in a very dangerous situation,” he said.
Despite these apparent benefits, HAT and SCS face profound legal resistance in the United States. Heroin is a Schedule I drug according to the Drug Enforcement Administration, meaning that it “has no currently accepted medical use and a high potential for abuse.”
Researchers are still able to conduct clinical trials with Schedule I substances, but such work involves a significant amount of bureaucracy and red tape.
HAT and SCS also face additional legal hurdles from the so-called “crack house statute” (21 USC § 856), a provision of the Controlled Substances Act, that can hold property owners and landlords responsible for properties where drugs are knowingly being used, distributed, or manufactured.
SCS are illegal throughout the United States, but several cities, including Denver, Philadelphia, and San Francisco, have begun toying with pilot programs.
However, in response to such a development in Vermont, the Department of Justice responded that these sites “would violate several federal criminal laws, including those prohibiting use of narcotics and maintaining a premises for the purpose of narcotics use. It is a crime, not only to use illicit narcotics, but to manage and maintain sites on which such drugs are used and distributed.”
According to the DOJ, people using drugs at these sites as well as workers, overseers, and properties owners could all have criminal charges brought against them under the Controlled Substances Act.
“It could be really interesting to see if one of these cities or states decides to go through with this. People will be paying really close attention to how the federal government does or does not react to them. If one of these jurisdictions does do this, depending on how the federal government reacts, that’s going to send a signal to other jurisdictions as well,” Kilmer said.
To solve some of the ethical and legal stigmas around these interventions, “you also have to demonstrate that HAT does not encourage people to initiate or escalate opioid use,” said Edward Bilsky, PhD, provost and chief academic officer at Pacific Northwest University of Health Sciences in Washington and an expert in opioid pharmacology.
“We have not addressed some of the underlying factors that raise risks and have not invested much in prevention efforts,” he added. “We are also still not adequately coordinating existing resources. As a result, we are turning to more extreme measures to try and stem the overdose deaths.”
Bilsky also agrees that HAT should be considered for trials in the United States.
The bottom line
There remain many questions about these interventions, from cost and legality to efficacy. But ultimately, the answers to these questions can only come from rigorous controlled trials.
“You can do trials and then step back and look at the data and then make decisions about whether or not this is something you want to continue or something you want to change,” Kilmer said.
Even piloting a trial of this nature would represent a seismic shift in the ethics, treatment, and policy of how we think about drugs and addiction in the United States.
As the opioid crisis bleeds Americans from every coast and walk of life, it may be time to consider every available option.