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)

In the NAOMI project, researchers monitored 251 heroin addicts in Vancouver and Montreal and provided them with maintenance drugs for a year under the supervision of nurses, doctors, social workers, and psychiatrists. One hundred fifteen received pharmaceutical heroin (diacetylmorphine), 111 received methadone, and 25 received Dilaudid (hydromorphone).

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.