Heroin-dependent clinical trial volunteers who received diacetylmorphine, the active ingredient in heroin, were far more likely to remain in the study than those who received methadone, according to a study published August 20 in The New England Journal of Medicine and reported by The New York Times. Those who received the controlled heroin injections were also more likely to refrain from illegal activities and illicit drug use, potentially reducing the risk of HIV infection or ongoing transmission.

Experts estimate that more than 1 million people in North America use heroin regularly. Of that number, up to 25 percent do not respond effectively to addiction treatment, including methadone.

In Western Europe, researchers have turned to medically prescribing heroin for treatment-unresponsive individuals to keep them from engaging in illicit and illegal activities, some of which are associated with substantially increased risks of HIV transmission. Some policymakers have looked askance at these efforts, however, fearing that it will only make things worse.

To determine the safety and efficacy of legally prescribed heroin to diminish illegal and unsafe activities, Eugenia Oviedo-Joekes, PhD, from the University of British Columbia in Vancouver, and her colleagues randomized 226 heavy heroin users who had previously returned to illicit heroin use while on methadone maintenance therapy to receive either diacetylmorphine or methadone. All of the patients also received addiction counseling. After one year, the patients were assessed for retention in the study or drug-free status and a reduction in illicit-drug use (outside of the study drug) or other illegal activities.

Legally prescribed heroin, the study authors conclude, is an effective replacement therapy. Nearly 88 percent of the people who injected prescribed heroin stayed in the study for the full year, compared with only 54 percent of those who received methadone. In terms of lowering illicit-drug use or other illegal activities, heroin trumped methadone again, with 67 percent of those receiving heroin reducing such activities compared with only 48 percent of those receiving methadone. There were also few signs of abuse in the study. The average dose of those receiving heroin was only 450 milligrams (mg), far less than the 1,000 mg maximum.

People receiving heroin did have more serious complications than people receiving methadone. Ten patients overdosed, and six had seizures in the heroin arm. The authors say this indicates that people receiving prescribed heroin should do so in a medically controlled environment.

“The main finding is that, for this group that is generally written off, both methadone and prescription heroin can provide real benefits,” said the senior author of the study, Martin Schechter, MD, PhD, a professor at the University of British Columbia.

Whether this promising addiction treatment strategy will become a reality in the United States—a country that some harm reduction activists say appears to be at war more with addicts than addiction—is hard to say. In an editorial accompanying the study in the NEJM, Virginia Berridge from the London School of Hygiene and Tropical Medicine concludes, “The rise and fall of methods of treatment in this controversial area owe their rationale to evidence, but they also often owe more to the politics of the situation.”