AMSTERDAM, the Netherlands - On a quiet alley in east Amsterdam, a security guard stands watch outside a brick office building, which 75 men and women visit twice a day to smoke or shoot up government-funded heroin.

Public-health experts in the Netherlands say free distribution is one reason that drug-related deaths are far less common than in the United States. The program also has reduced crime and improved the quality of life for many users, according to Ellen van den Hoogen, who runs the clinic.

Is it an answer for the United States, where the opioid epidemic continues to claim more than 100 lives every day? Maybe it should be, said van den Hoogen. "It's been an enormous success. I think it would work elsewhere."

Indeed, it has worked elsewhere. The Netherlands program started in 1998, modeled after a similar, successful effort in Switzerland. Several other European countries, including Germany and the United Kingdom, have adopted the model as well.

The concept is rooted in several key ideas:

* Drug addiction, for some, should be treated as a chronic disorder, not a condition that can be "cured," and may be best treated with supervised drug use in a clinical setting.

* The goal of treatment doesn't have to be the complete cessation of drug use: It can be the reduction of criminal activity and the improvement of physical and mental health.

* Public health policies should be determined by pragmatism, not morality.

Only the most hardened drug abusers qualify for the program in the Netherlands: They must be at least 35 years old, regular heroin users for at least five years, and repeatedly unsuccessful in other treatment efforts, including methadone-maintenance therapy. It's a last-resort option.

"It's not a program that is meant to help you stop," acknowledged van den Hoogen. "It keeps you addicted."

The concept offends John P. Walters, the drug czar under President George W. Bush, who is currently chief operating officer of the conservative Hudson Institute. "Keeping people addicted for the purposes of controlling them? Is that a policy that is consistent with the moral foundations of a moral society?" he asked.

He has practical, as well as philosophical, objections: In the United States, opioid-addiction rates have skyrocketed in recent years; in 2016, more than 64,000 Americans died of an opioid overdose. "How big of a colony of state-supported, locked-up addicts do you want to create?" he asked.

Opioid abuse rates in the Netherlands are much lower: In 2016, just 235 residents of the Netherlands died of an opioid overdose, compared to 4,050 in Ohio -- and Ohio has far fewer people.

Walters is no fan of current U.S. drug policy, but he doesn't think that government-supplied heroin is the answer. Instead of giving people heroin, he argued, "Do real treatment, do real outreach."

Peter Blanken, a senior researcher with the Parnassia Addiction Research Centre in Rotterdam, believes that heroin-assisted treatment is "real treatment."

His research found that approximately 1 in 4 participants makes what the program considers a "complete recovery," including better health and cessation of illegal drug use and excessive alcohol consumption. Some participants, he added, do stop using heroin completely, although that is not the goal of the program and those numbers are not tracked.

U.S. cities consider supervised-injection sites

The U.S. has not even begun to debate whether to embrace heroin-assisted treatment. But a related idea, that people with addiction should be provided a safe place to use, is gaining some traction.

These safe spaces are called supervised, or safe, injection sites. There, people can use drugs under the watchful eyes of observers who are trained to help in case of an overdose or other health issue.

Politicians and law-enforcement officers are divided on the issue.

Government officials in New York City, Philadelphia, San Francisco, Seattle, and the small western New York town of Ithaca, are considering such pilot projects, even though they would violate federal drug laws.

Canada has experimented with supervised injection sites in recent years; at least six have opened in Toronto since early 2017.

The idea has not been discussed in Cleveland, according to Vince Caraffi, chair of Cuyahoga County's Opiate Task Force and a supervisor with the Cuyahoga County Board of Health.

Caraffi imagined the political opposition to such an idea would be intense in a place like Ohio, where even needle-exchange programs remain controversial in some parts of the state.

"It will be interesting to see, as these cities develop these sites, if they alleviate deaths," said Caraffi. "They make sense from a harm-reduction standpoint."

There are two key differences between these supervised injection sites and the heroin-assisted treatment centers in Europe: Who provides the drugs, and what they're likely to contain.

In Amsterdam, participants are given pure, pharmaceutical-grade heroin. It's powerful, but it's predictable. There is no risk of contamination with potentially lethal drugs like fentanyl, which have killed many American users.

At supervised injection sites, participants bring their own drugs. They obtain them illegally, and risk contamination from additives or synthetic heroin substitutes.

The goal of these supervised sites is to reduce the number of deaths from opioid overdoses. But the crimes associated with the illegal drug trade continue, said Katharine Neill Harris, a drug policy expert at Rice University's Baker Institute.

Harris, a supporter of heroin-assisted treatment, called these supervised injection sites "a step in the right direction," but ultimately, she'd like to see the European model implemented in the United States.

"I think it makes a lot of sense from a pragmatic approach," she said. "There are all these benefits that outweigh the harm."

Back in Amsterdam

Now into its second decade, heroin-assisted treatment is established drug policy in the Netherlands, a country known for its liberalism. The biggest controversy in recent years came last December, when the Amsterdam clinics had to reduce hours due to a nation-wide nursing shortage.

The program is administered in a clinical setting. Participants have access to supplemental care, from mental health services to housing support. If patients want to stop doing drugs, help is available, said van den Hoogen.

Frank Paauy, a heroin patient for more than a decade, said that the drug program can be overly intrusive. "It's getting to be too much -- the interference in your life," said Paauy, who complained about officials asking about drug use away from the clinic and how he spends his money.

"They get a bit personal," he said. They may have reason for asking; he admits that he sometimes uses the money he saves on heroin to buy crack cocaine.

At his 10:30 a.m. appointment on a recent Tuesday, Paauy and five others sit in a semi-circle, facing a window, and smoke pharmaceutical-grade heroin for about 30 minutes. On the other side of the glass, two nurses look on.

Paauy used to come to the clinic three times a day, until hours were cut last year; now he comes twice a day.

"I'm not feeling 100 percent anymore," said Paauy, who looks older than his 59 years. "I wish they were still open in the evenings."

U.S. approach to drug abuse isn't working

Harris, with Rice's Baker Institute, lauds Europe's holistic approach to drug addiction, linking drug treatment with health care, mental health care and social welfare programs. She said supervised-injection sites in the United States, too, could connect people to the care they need.

Heroin-assisted treatment in Europe, she said, has removed some of the drug's allure: It's no longer the drug of rebellious young people, but a drug for aging sick people.

Besides, she said, chemically, there isn't much difference between heroin and other opioids, including prescription pain medication. "There's less of a stigma to prescription pills than to heroin," she said. "But both act on the brain essentially the same way."

Harris believes the United States may be inching toward a more comprehensive approach to drug use. Marijuana is legal, in some form, in 29 states. And there is growing acceptance of medication-assisted treatment for opioid addiction -- treatment that uses other drugs, including methadone and Vivitrol, to combat withdrawal and other side effects.

The evidence is overwhelming that the current response to the U.S. drug crisis isn't working, she said. "The prohibition model, where you focus on targeting the supplier, doesn't work. As long as there is demand, someone will meet it."

She added: "The conversation is changing. Increasingly, people are seeing the futility of the war on drugs and think that changes need to be made in the way we deal with this."

Those changes are not coming fast enough for Howard Wooldridge, a former Michigan police officer who now heads an organization called Citizens Opposing Prohibition.

He called America's war on drugs "a horrific failure," responsible for a large percentage of crime in the United States, and 120 unnecessary opioid overdose deaths every day.

He recently distributed a summary of the Swiss heroin-assisted treatment program to every member of Congress. He said he has gotten no serious response from anyone.

He's looking for an American citizen, someone addicted to heroin, who has failed at other forms of treatment, to travel to Switzerland and give that country's program a try.

The Swiss, he said, have administered more than 10 million doses of heroin to their patients. "And no one has died," he said. "Nobody has to die from heroin."

Wooldridge is quick to point out that he does not support recreational drug use. "Drugs are dangerous. That's not the issue. But how is prohibition helping anything?"

Walters, the former drug czar, strongly opposes the legalization of drugs as a means to decrease abuse and addiction. The most effective way to decrease use and abuse, he said, is to cut off supply.

He argues for an approach similar in scale to the U.S. response to the September 11 terrorist attacks, when 3,000 Americans were killed. In 2016, drugs killed 64,000 Americans.

"We're facing a slaughter of historic proportions," he said. "Why isn't the urgency overwhelming? Why isn't there more of a public outcry?"

He said he understands that "people are desperate for an answer." But, he says, neither government-provided nor government-supervised drug use is the answer.

European heroin use decreasing

Back in Amsterdam, Ellen van den Hoogen corrects a visitor who refers to heroin as "legal" in the Netherlands.

"It's not legal here," she said. There is still an illegal heroin market in the country, though it is much smaller than it used to be.

Critics who feared that providing free heroin to people with addiction would encourage abuse have been proven wrong, she said. In fact, heroin use is way down in the Netherlands.

"That's like saying that giving people condoms encourages sex," she said. "Or that people will use heroin because you give them a clean needle."

According to Dutch researcher Blanken, the number of people addicted to heroin in the Netherlands has declined significantly in the past two decades, from as many as 29,000 in the late 1990s to as few as 14,000 today.

Admittedly, the Netherlands' struggles with heroin, which date back to the counterculture movement in the 1970s and '80s, is much different from the epidemic that has overtaken the United States. The overuse of prescription pain medication has not been a problem in Europe the way it has in North America.

In the Netherlands, heroin addicts are almost all over age 50. Young people know it's dangerously addictive, and stay away, said van den Hoogen.

Amsterdam's heroin-assisted treatment program, housed at two municipal health clinics, is down to just 145 participants.

"We have vacancies," she said. And she's fine with that.

Editor's note: Plain Dealer Travel editor Susan Glaser visited Amsterdam in mid-May. During her time there, she toured one of the city's heroin-assisted treatment clinics, talked with director Ellen van den Hoogen and interviewed patient Frank Paauy.