Heroin Works Better Than Methadone, So Why Won’t Politicians Allow It?

Jesse Singal on why politicians still can’t accept the idea of treating heroin addicts with heroin.

During the health-care debate in 2010, some politicians were fond of issuing dire warnings of government bureaucrats “coming between you and your doctor.” But when it comes to treating heroin addiction, it’s often the politicians themselves who are barring the door.

A study released today in the Canadian Medical Association Journal suggests that giving heroin to addicts who have been resistant to treatment, instead of the traditional methadone, may in the end be the most cost-effective way to mitigate the societal damage done by this form of addiction.

It’s the latest in a string of clinical investigations pointing to heroin-assisted therapy—or HAT—as the best way to attack a scourge that costs the U.S. about $22 billion each year.

“What this study has shown is, for people who fail methadone, don’t put them on methadone again,” said Dr. Aslam Anis, director of the Centre for Health Evaluation and Outcome Sciences at Providence Health Care in Vancouver and an author of the study. “There’s a better option: put them on heroin. You’ll end up saving money and doing better.”

Sounds great—the only problem is, in the current U.S. political environment, it will never happen.

HAT, also known as heroin maintenance, is based on the premise that while methadone treatment is effective by many standards, most methadone users end up back on heroin or other opiates eventually—either with or without methadone supplementing their habit.

Since the search for heroin is, in many ways, more harmful to society than the use of it, methadone may have important limitations as a means of mitigating the damage done by heroin addiction.

Monday’s study is the second to come out of the first North American clinical trial of medically prescribed heroin, known as the North American Opiate Medication Initiative (NAOMI). For three years, NAOMI targeted long-term heroin users in Montreal and Vancouver (a city with a history of heroin issues) who had already sought treatment at least twice without success.

The first NAOMI study, published in the New England Journal of Medicine in 2009, confirmed the findings of several European studies that heroin maintenance is a safe and efficient way to deal with long-term heroin addiction.

In the new study, researchers found that heroin—despite being up to 10 times as expensive as methadone—is also more cost-effective, in part because users are more likely to stay in treatment on heroin than on methadone. How long users stay in treatment is key to mitigating societal damage, since it keeps them in contact with the medical system and lessens or even prevents other health and crime problems that stem from heroin dependency.

The NAOMI numbers are striking. A year after the start of the study, nearly 90 percent of those given heroin remained in treatment, while just over half in the methadone group did. And giving users injectable heroin reduced their rate of “illicit-drug use or other illegal activity” by 67 percent, while this number was under 50 percent for the methadone group.

But what the study shows perhaps even more starkly is how far behind the curve the United States is when it comes to addiction issues.

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HAT is already old news in parts of Europe, where it is an established facet of addiction treatment. It has been implemented most notably in Switzerland and the Netherlands—both of which tend to take more open-minded approaches to addiction policy—and it exists in a limited capacity in the U.K. and Germany. (Portugal decriminalized all drugs in 2001—a policy that appears to be a success so far.)

Each country applies HAT a bit differently, but the general outline is the same: long-term users are administered heroin in a clinical setting, with safeguards to prevent the drug from leaking onto the black market.

“It’s not controversial in either [Switzerland or the Netherlands],” said Peter Reuter, a policy analyst at the University of Maryland’s School of Public Policy, “and in Switzerland it’s been there for so long that people have forgotten that it was once controversial.”

In the United States it’s a different story altogether.

Our tendency to defer to politicians who court votes, rather than scientists who study addiction, manifests in a variety of ways, from our penchant for locking up drug offenders to our unending supply of sensationalized reporting on the subject.

Recall former New York mayor Rudy Giuliani proposing in 1999 to shut down the city’s methadone clinics, or Sen. John McCain, leading up to his first run for president, calling methadone treatment “disgusting and immoral” and “an Orwellian drug swap.”

While other countries move forward on cheaper and more effective ways to treat drug addicts, we remain mired in arguments over needle exchanges and methadone clinics—issues that are more or less settled in the public-health community. (And don’t forget the ever-powerful NIMBY factor.)

Compared with other wealthy democracies, “what’s striking is not how punitive we are, but how unwilling we have been to take an evidence-based perspective on matters pertaining to both harm reduction and to law enforcement measures to deter drug use,” said Harold Pollack, a professor of social-service administration at the University of Chicago, in an email. “And that underlying mindset perpetuates our poor track record in HIV prevention, drug treatment, and other areas of drug policy.”

In the hope of winning the economic argument, Anis and his colleagues have set up an online tool where anyone with basic demographic information about a city or state can estimate how much money implementing HAT would save.

“When people are in treatment and they’re retained, they live normal lives and their criminal activity is reduced, justice systems spend less money keeping them incarcerated,” Anis said. “So when you take all those costs into account, even though the drug cost is higher, [because of] the savings that accrue from the other parts of the economy, on net it’s cheaper.”

Still, even researchers sold on HAT’s promise will themselves admit that the idea of giving heroin addicts heroin is hard for many people to swallow.

“You sort of have to get over some pretty large hurdles of face implausibility,” Reuter said. “There’s something strange about the notion that on the one hand you prohibit this drug, but … if the user causes enough damage to society and to himself, well, we’ll give it to you free.”