In a report that was actually completed last October but not published until this week in the New England Journal of Medicine, researchers from the North American Opiate Medication Initiative (NAOMI) found that giving heroin under supervision to some hard-core drug addicts was more effective than giving them methadone. The study's publication in the prestigious peer-reviewed journal is already leading to calls for experiments with heroin maintenance in the US. To qualify for the study, participants had to have been addicted to heroin, Dilaudid, or another opiate for at least five years, have been injecting for at least the past year, have tried addiction treatment, including methadone maintenance, at least twice, and be at least 25 years of age. While researchers were loathe to generalize their findings, they described heroin maintenance as "a safe and effective treatment" for chronic addicts who have not taken to other forms of treatment.

Hastings St., downtown Vancouver (from vandu.org)

Among participants who received heroin by injection, 88% completed the program compared to 54% of those receiving oral methadone. Similarly, illicit drug use rates dropped by 67% among those receiving heroin, compared to 48% among those receiving methadone.

"Our data show remarkable retention rates and significant improvements in illicit heroin use, illegal activity and health for participants receiving injection assisted therapy, as well as those assigned to optimized methadone maintenance," said Dr. Martin Schechter, principal investigator for the Center for Health Evaluation and Outcome Sciences at the University of British Columbia School of Population and Public Health and NAOMI's lead researcher. "Prior to NAOMI, all of the study participants had not benefited from repeated standard addiction treatments. Society had basically written them off as impossible to treat," he said.

"We now have evidence to show that heroin-assisted therapy is a safe and effective treatment for people with chronic heroin addiction who have not benefited from previous treatments. A combination of optimal therapies -- as delivered in the NAOMI clinics -- can attract those most severely addicted to heroin, keep them in treatment and more importantly, help to improve their social and medical conditions," explained Schechter.

The NAOMI research results mirror similar findings from a number of European countries, a fact noted in a Journal editorial by Virginia Berridge. "The results of this trial may be added to those from Germany, the Netherlands, Spain and Switzerland," Berridge wrote. "Switzerland has 10 years of experience in the prescription of heroin, and in a November 2008 referendum, 68% of voters were in favor of its continued prescription."

The NAOMI findings, along with earlier work from Europe, are relevant to the United States. According to government figures, nearly 700,000 Americans are heroin users, and 15% to 25% of them are heavy users who could benefit from prescription heroin.

But heroin is a Schedule I drug under the US Controlled Substances Act, which means it cannot legally be prescribed. That is unlikely to change anytime soon. Even allowing for a pilot program would require political decisions that are unlikely to be made in the foreseeable future.

That needs to change, said advocates of evidence-based drug policies. "The NAOMI results are clear that prescription heroin reduces crime, and overdose deaths," said Laura Thomas, deputy state director of the Drug Policy Alliance. "The reason this effective treatment isn't available in the United States right now is politics. The science is there."

"The success of NAOMI, combined with similar results in other countries, leaves little question that heroin prescription would reduce crime, and overdose fatalities in the United States as well," added DPA executive director Ethan Nadelmann. "Recent votes in Germany and Switzerland, combined with similar evidence of public support in other countries, show that the public will support even controversial drug policies when they have proven results. There is no question that heroin prescription programs are needed and long overdue in this country. All that stands in the way is ideology and the backward assumption that it can never happen in the United States."

It wasn't just DPA wondering about more effective forms of drug treatment. In a blog post titled Prescription Heroin?, New York Times science columnist John Tierney asked just that: Is it time for prescription heroin in the US? He didn't provide an answer, but the fact that the question is being asked by someone like Tierney is suggestive.

And if not prescription heroin, what about Dilaudid? It is Schedule II and can be prescribed, although not, under current law, for maintenance purposes. Schecter and his fellow researchers found that NAOMI participants could not distinguish it from heroin and that it appeared to be equally effective.

In a bid to promote opiate maintenance therapy behind bars, the British government has begun installing methadone vending machines in the country's prisons. Justice Minister Phil Hope told parliament last week that 57 vending machines have been installed so far.

The machines allow prisoners to receive an individualized dose of methadone by giving a fingerprint or an iris scan. The machines are paid for by the Department of Health and will cost about $6.5 million dollars, about 10% of the department's prison drug treatment budget. The target is to have the machines in half of Britain's 140 prisons.

According to the latest available prison population statistics, in 2007, nearly 6,400 of Britain's 81,000 prisoners were there on drug charges, with slightly more than half of them charged with simple drug possession or possession with intent to distribute. The official statistics provide no breakdown of which drugs were involved.

"Methadone dispensers are a safe and secure method for providing a prescribed treatment," said a health department spokesman. "They can only be accessed by the person who has been clinically assessed as needing methadone and that person is recognized by a biometric marker, such as their iris."

Providing methadone to addicted prisoners allows them to manage their habits without resorting to illicit heroin supplies within the prisons. But the opposition Conservatives were quick to try to score political points, claiming that the Labor government would rather "manage offenders' addiction" than end it.

"The public will be shocked that Ministers are spending more on methadone vending machines than the entire budget for abstinence based treatments," said Dominic Grieve, the Conservative shadow justice secretary. "Getting prisoners clean of drugs is one of the keys to getting them to go straight. We need to get prisoners off all drug addiction -- not substitute one dependency for another. The government's approach of trying to 'manage' addiction is an admission of failure."

The Conservatives are hammering away at Labor any way they can as they prepare for national elections sometime in the coming months. Attacking enlightened approaches to inmate drug addiction is just another arrow in their "tough on crime" quiver.

The German parliament has voted to allow the prescription of heroin to addicts who have not responded to other treatments. The lower house of parliament approved the measure May 28.

Under the new law, heroin users who have been using for at least five years, are at least 23 years old, and who have failed to stop in other treatment programs will be able to receive pharmaceutical heroin in designated treatment centers. The law follows a German pilot program conducted in seven cities between 2002 and 2006 that showed impressive results in reducing crime, overdose fatalities, and HIV among hard-core users.

Similar results have been reported in Britain, Canada, the Netherlands, Spain, and Switzerland. Last year, Swiss voters legalized prescription heroin in a public referendum.

The news was welcomed by drug reformers around the planet. "The success of the German heroin prescription projects, combined with similar results in other countries, leaves little question that heroin prescription could reduce crime, HIV and overdose fatalities in the United States as well," said Ethan Nadelmann, executive director of the Drug Policy Alliance. "And [the May 28] vote in Germany, combined with similar evidence of public support in other countries shows that the public will support even controversial drug policies when they are given a chance to prove themselves. There is no question that heroin prescription programs are needed and long overdue in this country. All that stands in the way is politics and the backward assumption that it can never happen in the United States."

The Australian group Families and Friends for Drug Law Reform likewise used the German vote to agitate for similar policies Down Under. "The German decision challenges Australia to remove John Howard's veto of this medical treatment and put humanity and social well-being first," said Brian McConnell, President of Families and Friends for Drug Law Reform. "The veto of the decision of the Australian Health Ministers in 1997 for a heroin trial must be reviewed in the light of the rising number of overdose deaths and the threat of a renewed flood of Afghan heroin," he said

"Excuses for not introducing it have become baseless given the overwhelming evidence that now exists in support of the measures," McConnell added. "Attracting the severely addicted into treatment, away from recruiting and selling to new users to support their habit, will surely allay parents' and governments' concerns about the provision of this treatment. It can undermine organized crime's profit from heroin, which is critical at a time when world production of heroin is increasing. Much is to be gained with this common sense measure: there are lives to be saved, individuals' health to improve and a huge potential for reduced crime and trafficking in illegal heroin."

Beginning sometime next month, hard core heroin users in Denmark will be able to receive two doses of heroin a day, courtesy of the Danish health system. They will have to go to one of five drug clinics established around the country, where they will be able to inject pharmaceutical grade heroin under a doctor's supervision.

downtown Copenhagen

Denmark thus joins a small but growing number of European countries, including Switzerland, the Netherlands, and Great Britain that have heroin maintenance programs. The goal is harm reduction.

"The aim is to improve their state of health, help them avoid committing crimes and stabilize their lives," Dr. Anne Mette Doms of the Danish Board of Health told the British newspaperThe Guardian. "Quitting altogether is not a realistic option for most of these patients. For them, this will be a chronic treatment, as if you were treating a chronic disease."

Support for such programs is a welcome change, said Preben Brandt, chairman of the Council for Socially Marginalized People. "Five years ago I decided I would not participate in yet another debate on drugs," he told the Guardian. "It was too emotional, with different groups being very aggressive. The counter-argument was always 'you kill people by giving heroin' or 'with this initiative, you are telling people that taking heroin is OK'," he said. "It is very difficult to have a rational debate when you are arguing against beliefs."

But successes in other European countries experimenting with heroin maintenance helped change the atmosphere, said Mads Uffe Pedersen, head of the Center for Alcohol and Drug Research at the University of Aarhus. "The politicians became convinced that it could help those with the most severe drug problems," he said. "You could not argue against the (positive) findings."

"The debate became more practical," agreed Brandt. "It was about what policies worked and which ones did not. It was no longer about morality."

And changing attitudes toward drug users also helped, Brandt said. "Drug addicts in Denmark are less stigmatized. They are no longer perceived as criminals who are a danger to society. They're seen as patients who have a disease they need help with. The new scapegoats in Denmark are the foreigners."