There's no denying the U.S. is in the midst of an epidemic. Opioid drug overdoses now claim thousands of lives every day, including an increasing number of women. But actually solving our crisis requires thinking of addiction as a medical condition — and, some argue, thinking of opioid drugs as part of treatment. In fact, some researchers are finding that prescribing medical-grade heroin may be the most effective treatment in patients for whom other options have failed.
So far, only one place in North America is legally allowed to do this: Vancouver, B.C.'s Providence Crosstown Clinic. And today, Scott MacDonald, MD, lead physician at that clinic, testified alongside other researchers and activists at the U.S. Senate Committee on Homeland Security & Governmental Affairs in Washington D.C. to discuss alternate ways of tackling our current opioid epidemic. Ahead of Dr. MacDonald's testimony, we asked him about the Crosstown Clinic's radical approach — and how it might save lives in the U.S., too.
What is medication-assisted treatment?
When treating opioid use disorders, this strategy combines counseling and opioid medications that don't come with euphoria. These are intended to help patients deal with both cravings and withdrawal symptoms, so they can focus on the rest of their lives. Two of the most commonly-prescribed drugs for this purpose are suboxone and methadone. "[These medications] are good and work for most people, but not everyone," Dr. MacDonald says. "There is a small group who aren’t retained in care with those, so we need more options." For some, the drugs cause unbearable side effects, and for others, they just don't work. One alternative option is administering "prescription heroin," which is essentially pure, medical-grade diacetylmorphine hydrochloride, the active compound in heroin. A few recent clinical trials that Dr. MacDonald has been involved with have also found that hydromorphone (another potent opioid) works for many patients, too. The major difference between these and currently available drugs, besides the drugs themselves, is that they are all taken under supervision in the clinic. This approach is also different than that of supervised injection sites — at those clinics, only safe needles are provided.
When treating opioid use disorders, this strategy combines counseling and opioid medications that don't come with euphoria. These are intended to help patients deal with both cravings and withdrawal symptoms, so they can focus on the rest of their lives. Two of the most commonly-prescribed drugs for this purpose are suboxone and methadone. "[These medications] are good and work for most people, but not everyone," Dr. MacDonald says. "There is a small group who aren’t retained in care with those, so we need more options." For some, the drugs cause unbearable side effects, and for others, they just don't work. One alternative option is administering "prescription heroin," which is essentially pure, medical-grade diacetylmorphine hydrochloride, the active compound in heroin. A few recent clinical trials that Dr. MacDonald has been involved with have also found that hydromorphone (another potent opioid) works for many patients, too. The major difference between these and currently available drugs, besides the drugs themselves, is that they are all taken under supervision in the clinic. This approach is also different than that of supervised injection sites — at those clinics, only safe needles are provided.
Okay, but how does this actually work?
The Providence Crosstown Clinic is open every single day of the year, Dr. MacDonald explains. Each patient gets a scheduled time to come in; most come two or three times per day. Once inside, they go through a quick assessment to make sure they're well enough to proceed. Then, they are given seven minutes to use their drug under supervision, and clinic staff watches over them for another 15 minutes to make sure they're okay. The whole thing takes about 30 minutes.
Why do we think this would help the opioid epidemic?
Treatment with medical-grade heroin has already existed in various experimental forms for decades in other countries, such as Germany, Switzerland, and (more controversially) the U.K. Research looking at those sites has shown that treatment with diacetylmorphine is at least as effective as methadone at keeping patients in counseling and, eventually, reducing their opioid use. "It gets people off the streets, it helps them to stop using heroin and opioids, and it's cost-effective," says Dr. MacDonald. "The main benefits are saving lives and reducing costs [within the criminal justice system], and the secondary benefits are reducing social disorder, such as crime. There are many benefits, both to the individual and society." In the U.S., patients are already going to clinics daily to get methadone or suboxone, explains Dr. MacDonald, "so this is an intensified version of that." Although it wouldn't be too much of a logistical hassle to simply add the medical-grade heroin as another medication option, he points out that it would still require some serious regulatory changes. Right now, this practice is illegal. Ideally, introducing this type of treatment would occur alongside other evidence-based harm-reduction techniques, such as expanding access to the overdose-reversal drug naloxone and creating more supervised injection sites.
What other services does the clinic provide?
"There’s a variety of services, and we can provide comprehensive care," says Dr. MacDonald. That includes treatment for things like HIV, diabetes, high blood pressure, and mental illnesses. And should a patient wish to cut back his or her use or step down to suboxone or methadone at any point, Dr. MacDonald says the staff are more than happy to help with that, too.
The Providence Crosstown Clinic is open every single day of the year, Dr. MacDonald explains. Each patient gets a scheduled time to come in; most come two or three times per day. Once inside, they go through a quick assessment to make sure they're well enough to proceed. Then, they are given seven minutes to use their drug under supervision, and clinic staff watches over them for another 15 minutes to make sure they're okay. The whole thing takes about 30 minutes.
Why do we think this would help the opioid epidemic?
Treatment with medical-grade heroin has already existed in various experimental forms for decades in other countries, such as Germany, Switzerland, and (more controversially) the U.K. Research looking at those sites has shown that treatment with diacetylmorphine is at least as effective as methadone at keeping patients in counseling and, eventually, reducing their opioid use. "It gets people off the streets, it helps them to stop using heroin and opioids, and it's cost-effective," says Dr. MacDonald. "The main benefits are saving lives and reducing costs [within the criminal justice system], and the secondary benefits are reducing social disorder, such as crime. There are many benefits, both to the individual and society." In the U.S., patients are already going to clinics daily to get methadone or suboxone, explains Dr. MacDonald, "so this is an intensified version of that." Although it wouldn't be too much of a logistical hassle to simply add the medical-grade heroin as another medication option, he points out that it would still require some serious regulatory changes. Right now, this practice is illegal. Ideally, introducing this type of treatment would occur alongside other evidence-based harm-reduction techniques, such as expanding access to the overdose-reversal drug naloxone and creating more supervised injection sites.
What other services does the clinic provide?
"There’s a variety of services, and we can provide comprehensive care," says Dr. MacDonald. That includes treatment for things like HIV, diabetes, high blood pressure, and mental illnesses. And should a patient wish to cut back his or her use or step down to suboxone or methadone at any point, Dr. MacDonald says the staff are more than happy to help with that, too.