Providing supervised medical-grade heroin to heavy users can reduce harms

Providing supervised access to medical-grade heroin to people whose use continues after trying multiple traditional treatments has been successful in other countries, and should be piloted and studied in the United States, according to a new RAND Corporation study.

Evidence from other nations suggests that prescribing heroin to be injected under medical observation — with optional take-home methadone — can offer benefits over methadone alone for those who have repeatedly tried traditional treatments for heroin use disorder, including methadone, but still inject heroin, according to the analysis. This approach often is referred to as heroin-assisted treatment.

While the researchers say that the top priority is increasing access to traditional FDA-approved medications like methadone and buprenorphine, the severity of the opioid crisis provides urgency to evaluate other tools that might reduce its impact and save lives.

“Given the increasing number of deaths associated with fentanyl and successful use of heroin-assisted treatment abroad, the U.S. should pilot and study this approach in some cities,” said Beau Kilmer, leader of the project and co-director of the RAND Drug Policy Research Center. “This is not a silver bullet or first-line treatment. But there is evidence that it helps stabilize the lives of some people who use heroin.”

Researchers found studies from multiple countries suggesting that the approach can be more cost-beneficial than continuing to offer only methadone to those who have not responded well to methadone, notably because it is more effective at reducing criminal activity.

Opioid use disorders affect an estimated 9 out of every 1,000 Americans and opioid overdose-related deaths have quadrupled over the past 15 years. More than 49,000 people died from opioid-involved overdoses in the U.S. in 2017.

The RAND findings appear in five related RAND publications and are based upon one of the most-exhaustive analyses to date of the experiences in other parts of the world with two interventions that are implemented in some other countries, but not in the United States: heroin-assisted treatment and supervised consumption sites.

Supervised consumption sites, sometimes called drug consumption rooms or safe injection facilities, are places where individuals can consume already-purchased street drugs using sterile injection supplies in the presence of trained staff who monitor for overdose or risky injection practices, intervening when necessary. Some supervised consumption sites also provide additional services, such as referrals to treatment and access to drug content testing.

To assess the effectiveness of heroin-assisted treatment and supervised consumption sites, RAND researchers reviewed the high-quality scientific evidence and talked to more than two dozen stakeholders in Canada, the Netherlands, Switzerland and the United Kingdom to learn about their experiences with the approaches.

They also spoke to more than 150 people in New Hampshire and Ohio — including policy professionals, frontline service providers and people who use heroin or other opioids — to examine interest in the two approaches and perceived barriers. The two states have been hit hard by the U.S. opioid epidemic.

While the researchers found there were published clinical trials that support the benefits of heroin-assisted treatment, the full range of benefits of supervised consumption sites were not as well documented. The effects on consumption within a supervised consumption site are directly observed, but scientific evidence about the claimed and anticipated spill-over effects on behavior outside the facility’s walls is limited both in quality and in the number of locations evaluated.

Although the RAND study found that supervised consumption sites can reduce the risk of a fatal overdose, disease transmission and other harms associated with unhygienic drug use practices, there is uncertainty about the magnitude of population-level effects of the strategy. Yet many such programs have been around for 15 to 30 years and have survived multiple changes in local and national governments.

“Persistence does not imply effectiveness, but it seems unlikely that supervised consumption sites — which were initially controversial in many places — would have such longevity if they had serious adverse consequences for their clients or communities,” Kilmer said.

In the U.S., there are significant legal issues surrounding the implementation of supervised consumption sites. Interviews with international stakeholders also found that there often was vocal opposition to supervised consumption sites when initially discussed or opened. This opposition primarily revolved around concerns about enabling drug use and potential negative community effects. However, that resistance tended to dissipate over time.

The researchers suggest that it may be constructive to view heroin-assisted treatment and supervised consumption sites as exemplars of broader strategies, not as the only option within their class.

For example, supervised consumption sites currently supervise a very small proportion of all injection sessions even in cities where they are well established. Canadian cities recently have expanded the scale of supervised consumption by deploying smaller overdose prevention sites that typically offer fewer services than formal supervised consumption sites.

“It may even be worth asking whether the benefits of supervised consumption sites depend on there being a physical brick-and-mortar site, which may become a lightning rod for opposition, or if the key is just that consumption is supervised and whether there are other ways to get more opioid consumption supervised,” said Jonathan P. Caulkins, a report co-author and a professor of public policy at Carnegie Mellon University.

Caulkins said it also is possible that supervised injection of hydromorphone — a prescription opioid medication — may achieve similar benefits as offering supervised injectable heroin for those with heroin use disorder, but with fewer regulatory barriers.

While heroin cannot now be prescribed in the United States because it is a Schedule I drug, it would be legal under federal law to conduct randomized controlled trials with the drug, according to the study. Hydromorphone is classified as a Schedule II drug and is currently prescribed for pain.

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