A controversial — some say better — way to treat heroin addiction: Let addicts keep using

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Long-time heroin addicts who get supervised doses of the drug seem to stay in addiction treatment longer and have less criminal activity than similar addicts who get conventional methadone treatment. That’s the finding of a randomized controlled trial published this week in the New England Journal of Medicine. Researchers from two Canadian cities, Vancouver and Montreal, gave diacetylmorphine (heroin’s active ingredient) to 115 addicts and methadone to 111. While two thirds of the heroin group showed a decrease in outside illicit drug use and criminal behavior, in the methadone group less than half did.

What’s the point of addiction treatment if the addicts don’t actually quit? Every user enrolled in the trial had to be at least 25 years old and a heroin user for at least five years. They also had to have failed to kick the habit in treatment programs at least twice before, including once in a methadone-treatment program. In short, these were people who had struggled with addiction for a long time. It remains extremely controversial, but in parts of Europe and Canada policy-makers have gently proposed harm reduction. The idea is that, even if people can’t get clean, they could still get help to live healthier and more productive lives, avoiding some of the worst health risks of heroin — like HIV and hepatitis C, which are both spread through dirty needles — and eliminating a major reason for crimes like theft and prostitution, used to fund drug habits.

One major problem with the intervention reported in this week’s NEJM: adverse events. Six of the patients getting diacetylmorphine suffered seizures, and 10 had an overdose. In almost all of those cases, not surprisingly, the patients later reported that they had taken other drugs as well. (Diacetylmorphine doses in the trial were capped at a daily 1,000 mg.) All 16 people recovered, however, since they were in the clinic at the time and got prompt medical attention.

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