Baltimore is home to one of the nation's most intractable heroin-using populations, and now a study done for the city's Abell Foundation is suggesting it could be time to try something new, at least in this country: heroin maintenance. The idea is not so much to push for such a program now, but to open the door for discussion -- a worthy idea given that decades of repression and, more recently, conventional drug treatment have done little to stem the tide of addicts.

Authored by University of Maryland drug policy expert Peter Reuter, the study, Can Heroin Maintenance Help Baltimore?, examined existing heroin maintenance programs in Switzerland and Germany as well as the now-ended North American Opiate Maintenance Initiative (NAOMI) program in Vancouver, and examined the Baltimore heroin scene. His review of results so far found decreases in criminality, increases in employment, and health improvements for participants.

But Reuter also noted that those existing programs are expensive (more expensive than methadone treatment), serve relatively small numbers, and would be politically controversial in the US setting. In fact, the US National Institute on Drug Abuse, offered a chance to participate in the NAOMI program, declined. In addition, Reuter wrote that significant differences between hard core heroin users in Baltimore and in European cities made predictions of success difficult.

Can heroin maintenance help Baltimore? Here's how Reuter answered his own question:

At best there is a case only for an experiment. There are too many potential differences between Baltimore City and the other sites in which HAT [heroin-assisted therapy] has been tried to allow confident predictions of the outcomes. Visits to facilities in other countries hardly provide an inspiring model. The client population in Baltimore City is highly troubled so even if HAT leads to better outcomes for the group as a whole, many of the clients will remain unemployed, marginalized, and in poor health conditions. There will be some poster children but not many.

The potential for gain, however, is substantial. Even in the aging heroin-addict population, there are many who are heavily involved in crime and return frequently to the criminal justice system. Their continued involvement in street markets imposes a large burden on the community in the form of civil disorder that helps keep investment and jobs out. If heroin maintenance could remove 10 percent of Baltimore's most troubled heroin addicts from the streets, the result could be substantial reductions in crime and various other problems that greatly trouble the city. That is enough to make a debate on the matter worthwhile.

"It is a sensible innovation to consider," Reuter told the Baltimore Sun. "I am not a passionate advocate for it, but I do think someone should try it in the US. It has enough plausibility that it's worth trying."

But Baltimore officials are not convinced. "I think it would be a mistake to pursue an expensive and unproven idea when we need more resources for effective drug treatment," said Dr. Joshua Sharfstein, the city health commissioner, who apparently did not actually read the report. "There's nothing that persuades me to invest in something that is so expensive and without evidence."

Former Baltimore health commissioner Dr. Peter Beilenson worried that the notion was too radical to fly in the US and could undercut more plausible reforms. "It's not like everything has been tried and everything has failed and you just throw up your hands," said Beilenson, who is now Howard County's top health official. "The problem is if you are going to do any reasonable drug policy reform, this heroin thing is such a red flag that it takes all the attention away. It makes it look like anyone who is interested in drug policy reform is crazy." [Ed: Beilenson should know -- he tried it in 1998.]

But some addiction specialists said there should at least be a clinical trial. "Do I think it would be interesting? In a controlled clinical trial setting, yes," said Susan Sherman, an epidemiologist with the Johns Hopkins Bloomberg School of Public Health "To me, it's also important to have a public dialogue, regardless of the outcome. It forces people to deal with really hard issues about drug use and drug users."

"Most studies clearly show they help," said Dr. Christopher Welsh, assistant professor of psychiatry at the University of Maryland medical school. "But using public funds to fund something like this would be a whole other level of politics, especially in this economy."