Heroin-Assisted Treatment?

Stretching the Brain

Stretching the Brain

I came across an interesting study in this month’s issue of The American Journal of Addictions, Vol 22, (6) pp 598-604, titled, “Acute Effects of Heroin on Emotions in Heroin-Dependent Patients.”

I almost skipped over it, because I believe heroin-assisted treatment (HAT) to be less legitimate than MAT with methadone and buprenorphine. Then I realized I was doing the same thing anti-methadone people are doing; I was judging a potential treatment before getting all of the facts.

I’ve heard about heroin-assisted treatment before. I went to a lecture at an American Society of Addiction Medicine (ASAM) conference several years ago and heard a Canadian physician talk about North American Opiate Medications Initiative, or NAOMI. Our neighbors to the north did a randomized controlled trial in Vancouver and Montreal. This trial randomized opioid addicts to methadone maintenance treatment or heroin maintenance treatment. Sterile doses of heroin and sterile equipment to inject were provided to the patients in the heroin-maintained treatment arm. Medical personnel were at the injection site to care for patients with overdoses and other medical problems.

The study was designed to look at several endpoints. First of these was retention in treatment. In the heroin-maintained group, 88% were retained in treatment, compared to 54% of the patients on methadone maintenance. They study also looked at illicit drug use or other illegal activities, and found that patients in HAT improve significantly more than methadone maintained patients. HAT patients had a 67% reduction in illicit drug use or other illegal activities, and methadone-maintained patients had a 48% reduction in the same measures. However, serious adverse events were more common in HAT patients, mostly overdoses and seizures. Both groups had counseling made available for them.

Similar HAT programs are ongoing in Europe. Germany did a trial a few years ago, as did Spain, with mostly positive findings. In the Netherlands, HAT is now available for treatment-resistant opioid addicts who have not done well in more traditional methadone maintenance programs. The Swiss have been offering HAT since 1999, at twenty-three treatment centers. Their HAT studies showed reduced illicit drug use and criminal activity, better physical and mental health, and better social integration at the end of a two-year study. That study showed substantial numbers of patients transitioned to methadone maintenance or to abstinence.

A Cochrane review (see my blog post of September 19, 2013 for more information on the Cochrane Review group) concluded that data gathered on HAT shows reduced illicit substance use, reduced criminal activity, and possibly reduced mortality. However, MAT has a higher rate of serious adverse effects, and they recommended it to be considered as a last resort for treatment-refractory opioid addicts.

Can you imagine trying to open a heroin maintenance program in the U.S.? Yet such treatments exist in other countries, where addiction is seen as a medical problem to be solved rather than a moral problem that needs repentance. In Europe, there’s much more acceptance of methods that reduce harm in addicts.

Anyway, getting back to this study, Blum et. al. did a randomized controlled crossover trial with 28 heroin-dependent patients in treatment, and 20 healthy controls. They dosed the patients on HAT with either a placebo (saline) or with their usual dose of heroin, and then graded their emotional state. The study conclusion was that administration of heroin resulted in dampening of craving and negative emotions, and also increased positive emotions. The authors conclude that heroin regulates emotions and that opioid substitution treatment is of benefit for opioid addicts.

Your first inclination may be the same as mine: to say “Duh. Yes, heroin gives positive emotions. That’s why people like to use it.” But the authors of the study are also saying that the relationship between mood and substance use is complex, and that opioid addicts with advanced addiction are using opioids to alleviate negative emotions, rather than for the euphoria that they experienced earlier in their addiction. Of course, this study confirms what we see clinically, and what our patients tell use.

What came first, the depressed mood or the heroin use? And if these patients were in opioid withdrawal, then of course administering an opioid would make them feel more positive.

Some scientists say that some opioid addicts, even with no prior history of depression or anxiety, are vulnerable to negative emotion indefinitely after having an established opioid addiction, and that they may be unable to regulate their emotions like non-addicts do. Maybe this is the same thing as the post-acute withdrawal syndrome we see in opioid addicts after they are through acute withdrawal. Many recently withdrawal opioid addicts continue to feel bad, with sluggishness, depression, and overall malaise.

All of this information on heroin-assisted treatment of opioid addiction challenges me. I’m uncomfortable with the idea of providing pharmaceutical heroin to opioid addicts for maintenance. Heroin is short- acting, and some heroin addicts use it four or five times per day. I think they would be less stable than patients on very long-acting opioids like methadone as buprenorphine, which give a fairly stable blood levels for twenty-four hours. And the studies do show high rates of overdose with heroin maintenance.

I know the data about HAT clearly show this treatment benefits some patients, but I’m not willing to endorse it as a treatment, except maybe, possibly, for patients with severe opioid addiction who have failed other medication-assisted and abstinence-based treatments.

So…Am I all the way there as far as accepting heroin as a maintenance treatment for opioid addiction? No. But then, I’m a work in progress, as most of us are. After all, one person’s harm reduction is another’s enabling. I’m going to ponder heroin-assisted treatment for a little longer.

2 responses to this post.

  1. I’m more or less where you are, doc. I am guessing that there will be argument, but in my view the nature of short-acting vs. long-acting is the key here. I think that methadone and buprenorphine are sufficient for most opioid addicts needing/seeking medication assisted treatment. However, there are those who make up the percentages of people who do not/will not stay within or thrive within those systems for whatever reasons, and the fact that their continued illicit use is almost guaranteed to continue, why not make it as safe and stress-free as possible to at least create an environment where there might be a chance of productivity in a population that see’s very little productivity by societal standards? Seems like pretty straight forward harm-reduction to me..


  2. Posted by Benjamin K Phelps on May 8, 2015 at 2:00 am

    While I agree that overdose is much likelier to happen with short acting IV opioids, harm reduction beats, in my mind, no treatment at all or forced abstinence, which usually ends up causing an OD anyway when the addict gets hold on an opioid. Which is better? I don’t know. I just know that the fewer people that die from this disease, the better. That’s all I can say on the matter, no matter how much of a disdain we have for the idea of giving heroin to addicts. Just an opinion, though.


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