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Prescribing Heroin to Save Lives

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Another International Overdose Awareness Day (Aug. 31) approaches and many people are still focused on prescription opioid drugs and their role in overdose fatalities. Those do indeed play a big role. But another threat is snaking through the country and we need to plan for its impact.

Here comes the heroin.

Reports are coming in across the country, from places like Montgomery, Maryland, Ellensberg, Washington, Concord, New Hampshire, throughout Kentucky and in the Twin Cities, Minnesota. Heroin use and heroin overdoses are growing. According to recent research by SAMHSA (Substance Abuse and Mental Health Services Administration), the number of first-time heroin users has nearly doubled lately, from around 90,000 "first-timers" in 2006 to a whopping 178,000 in 2011. Our normal approaches (crackdown, get tough, prohibit, arrest) have never done much good long-term. Will anything be different this time?

Some people, including members of law enforcement, link the rise in heroin use to crackdowns on prescription drug abuse. We have been raiding pain clinics, thwarting 'doctor shoppers,' sentencing non-violent people, including elderly people, to long stretches in prison for low-level drug prescription drug sales. We know how to crackdown -- but we seem ignorant when it comes to what to do with all those addicted people we've "cracked down" on. You may thwart them with your database at the pharmacy, but they're still addicted. Now what?

Abuse-deterrent formulations of drugs and prescription drug take-back days are well and good, but they don't reverse an overdose, they don't educate about drug safety and they don't provide ready access to treatment. They don't address the factors that cause people to turn to drugs for relief and they don't acknowledge the uncomfortable fact that despite our best efforts, for some portion of the population, rehabs won't work, methadone won't work, and neither will cold turkey, tough love, prison, prayer or 12-Step.

Knowing that is true, we should take positive steps to address that reality with a health-oriented approach. We should bring the most marginalized populations back into the fold, increasing their interactions with physicians, counselors and other supportive service providers, without fear of arrest or incarceration, and without demanding abstinence.

We should consider the benefits of physician-supervised, prescription pharmaceutical heroin maintenance programs. Also called HAT (heroin assisted treatment) and HMT (heroin maintenance treatment), this treatment has been working for a number of years in places like Switzerland and Germany. These programs are predicated on the knowledge that some people, despite numerous efforts, cannot or will not stop using heroin and that their continued use in unsupervised settings creates costs related to arrests and incarceration, increased healthcare expenses, supporting the illicit drug trade, overdose, and loss of employment and housing.

These programs provide pharmaceutical heroin (diacetylmorphine) to a limited number of people who can demonstrate multiple failed attempts to achieve abstinence in other drug treatment programs, a multiyear history of injecting heroin, and in some cases physical co-morbidities. They visit the clinic one to three times per day and inject the drug under a doctor's supervision. They get off the street, out of public view and engage in a variety of other therapeutic services.

Sounds edgy, but it works. Reductions in crime, reductions in arrests, reductions in activity in open-air drug markets, reductions in fatal overdose, not to mention promotion of social integration, including considerable improvements in participants' housing situation and fitness for work. That's not speculation. That's fact.

Their positive results have been published in highly credible peer-reviewed journals. The efficacy is there, the research is there. Why aren't we at least trying this approach?

We need to get over our emotional response to the word 'heroin' and look at this treatment for what it is -- opiate replacement therapy, the same premise as methadone provision. This treatment is proven to help address the most severe, persistent and problematic heroin use while reducing costs to taxpayers and improving outcomes.

When it comes to addiction, every option should be on the table. That's just common sense. Anything that works, or shows great promise, however we feel about it, must at least be discussed -- seriously and carefully. We know of excellent ways forward to manage addiction, but we need the courage and sense to take them.

Meghan Ralston is the harm reduction manager for the Drug Policy Alliance(www.drugpolicy.org) in Los Angeles, CA.

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