Annamarya Scaccia

European programs offer medical-grade heroin for users to inject under strict supervision, and it’s helping – so why won’t it happen in the U.S.?

Diamorphine (heroin) prescription for a patient in a heroin-assisted treatment program, Germany.
 The opioid epidemic has gripped the United States, worsening day by day. Overdose deaths caused by opioids nearly tripled in a 15-year period. According to the U.S. Centers for Disease Control and Prevention, opioids, including heroin, accounted for about 63 percent of fatal overdoses in 2015.

More and more doctors are turning to medication-assisted treatment to curb the country’s opioid crisis. People addicted to painkillers or heroin are given opioid replacement drugs such as methadone to stabilize their drug dependency. Decades of research have shown that medication-assisted treatment is highly effective with long-lasting results.

But in a recent article for the Baker Institute blog on the Houston Chronicle‘s website, drug policy expert Katharine Neill Harris argues for bringing heroin-assisted treatment to the United States. Germany, Belgium, Denmark, the Netherlands and the United Kingdom have all launched heroin-assisted treatment programs, commonly referred to as HAT, that have shown to have a significant impact on reducing opioid use and overdoses, as well as related diseases such as HIV and hepatitis C.

“For certain people, heroin is preferable,” Neill Harris tells Rolling Stone. “It could help them stay in treatment for longer.”

What is heroin-assisted treatment and how does it help fight opioid addiction? Here is everything you need to know about the controversial treatment.

How does heroin-assisted treatment work?
People who are addicted to opioids can visit a specialized clinic, where they would get pharmaceutical-grade heroin – referred to as either diacetylmorphine or diamorphine – up to three doses a day, in most cases. A person in an HAT program would use medically-prescribed heroin on site, under careful supervision of a health care professional who would watch out for side effects. But it’s not a standalone therapy; HAT is often given in conjunction with psychotherapy and other social services. All together, this reduces the risk of overdose, as well as the demand for street heroin and criminal activity associated with scoring drugs, says Neill Harris, a drug policy fellow at Rice University’s Baker Institute for Public Policy.

How is HAT different than medication-assisted treatment?
Heroin-assisted treatment is actually not that much different than the more traditional medication-assisted treatment – or MAT. As Neill Harris described it, HAT uses prescription-grade heroin instead of what she labels as “replacement drugs” – meaning methadone, buprenorphine or naltrexone, the most common medications used to treat opioid addiction. Both therapies help jumpstart the same receptors activated by opioids that cause a high, but with a longer-lasting effect, reducing cravings and withdrawal symptoms. (Naltrexone works differently from methadone and buprenorphine; it’s an opioid antagonist drug that blocks those receptors, so if a person relapses, they won’t feel a euphoric high.) HAT, though, is a more expensive therapy option compared to medication-assisted treatment, according to the Drug Policy Alliance.

What does research say about heroin-assisted treatment?
A 2008 study discovered that people in Germany’s HAT program were more likely to stay in treatment and less likely to use street heroin or cocaine than those in methadone treatment. (Another study found people in heroin-assisted treatment are also less likely to abuse benzodiazepine — or benzo for short.)

Researchers also found that, although both methods led to improved mental and physical health outcomes, the results of HAT were more pronounced — findings replicated in a 2011 German studyA 2010 randomized trial and a 2015 meta-analysis also confirmed that illicit drug use was greatly reduced among people in heroin-assisted treatment as compared to those taking methadone. “There’s also evidence that heroin is associated with a greater reduced involvement in criminal activity and also a lower risk of incarceration,” Neill Harris says.

Who does heroin-assisted treatment help?
Heroin-assisted treatment is designed to help severely opioid-dependent people who are resistant to other therapies, including MAT. According to the National Institutes of Health’s National Institute on Drug Abuse (NIDA), medication-assisted treatment hadn’t work well for up to 40 percent of people addicted to opioids.

That’s because people who don’t respond to other treatments require very high doses of heroin, says NIDA Director Dr. Nora D. Volkow, an expert on medication-assisted treatment. “By providing that heroin at very specific times, at very specific doses to try to sustain that stability,” Volkow tells Rolling Stone, “these programs are helping them not to crave and not to go into withdrawal.”

Most heroin-assisted treatment programs follow the same basic tenets: Current heroin users who enroll must do so of their own free will, must have tried multiple other treatments without success and must be legal adults. But HAT also has a “tremendous” disadvantage, Volkow notes: High doses of heroin carry a greater risk of overdose, which requires doctors to monitor use “very very closely,” she says.


Initially, I tend against this type of therapy.  My experience is with buprenorphine.  There are occasional patients who don’t tolerate the naloxone in the mixed-products (Suboxone, Bunavail, Zubsolv) due to nausea and vomiting.  It would be good to have another tool in the ol’ toolbelt to help those folks.  They’re talking about dosing 3 times/d which is necessary with IV heroin.  I see that as a big drawback.  Methadone & buprenorphine are both dosed once daily.   I don’t think this would be as good a therapy as buprenorphine, but it may be worth having it available for the rare patient who doesn’t do well on either BUP or MTD for their opiate replacement needs.

Dr. Raymond Oenbrink