A controversial approach to the heroin addiction problem. Instead of giving methadone to patients, pure heroin is administered in a clinical environment. While this initially seems to be missing the point, by giving druggies the drugs they crave, it has been shown to improve the conditions a heroin addict faces, such as:
  • Long-term side effects. Contrary to popular belief, pure heroin has no negative physical long-term side effects. All long-term damage, such as tract marks, connective tissue damage, or neurochemical damage, is indirectly caused by the War on Drugs, in two ways. First, it economically encourages suppliers to dilute pure heroin with other powdered substances, many of which cause long-term damage when injected. Second, junkies rarely have access to clean needles, and even more rarely have access to professional training in the proper use of needles, resulting in the injection of air bubbles and often leading to permanent scarring ("tract marks"). Needless to say, this social stigma has also encouraged the spread of many blood-borne diseases like AIDS.
  • Acute side effects. A patient in a heroin-maintenance program is given a measured quantity of pure heroin, preventing the possibility of overdose, as well as a safe environment to take the dose in, preventing the patient from passing out in an alley and suffering from exposure or worse.
  • Social effects. Coupled with any good heroin maintenance program (such as the one in Switzerland, discussed below) are social services which help an addict reintegrate into society.
  • Societal costs. As stated time and time again by legalization advocates, jailing an addict is often more costly to society than treating him. A functional addict can work at a job, have a family, and otherwise contribute to society in ways that a jailed addict cannot. Furthermore, addicts in a maintenance program do not need to commit crimes to earn the fast cash necessary to pay for heroin, a typically expensive drug.

Even though this seems like a radical new idea, prescription heroin maintenance was standard practice in some countries (such as England) until the early 70s, when the United States put pressure on these countries to stop.

The Study

The first major study of heroin maintenance's feasibility was conducted in Switzerland between 1995 to 1998. They were initially conducted by the Swiss Federal Office of Public Health, but later were overseen by the World Health Organization. The study had a thousand participants, a substantial portion of Switzerland's estimated 13,000 methadone patients. The study examined the effects of injected heroin, injected methadone, injected morphine, and heroin-impregnated cigarettes, a delivery system that has since made its way into other heroin maintenance programs.

The Results

The study proved, within scientific methodologies, that heroin maintenance is feasible. Patients can be maintained on a stable dose of heroin. Drug use (including heroin and other drugs) declined, and significant improvements were noted in patients' health and social functioning (such as employment).

Heroin maintenance, it would seem, is useful for treating heroin addicts.

But why heroin? We've already got methadone...

As any heroin addict will tell you, methadone sucks. Some claim it is even more addictive than heroin, and in any case, it doesn't get you high. From a social-benefit standpoint, you can entice a lot more addicts to enter treatment if you offer them the drug they crave, and in turn can convert them into "useful" members of society.

In any case, as of a 1999 public vote, heroin maintenance is a legal practice is Switzerland.

Would it work in the US?

Probably a moot question, at least in the near future. The DEA classifies heroin as a Schedule 1 drug, which means that heroin is not seen to have any medical use and is not eligible for prescription. And in the current political environment, it seems highly unlikely that anyone is willing to suggest controversial treatments over throwing addicts in jail.

Aside from that, it must be noted that what works in one society may not work in another. The success of the Swiss study is likely tied directly to the social programs that accompanied treatment; without helping addicts find jobs and rebuild lives, the program likely would have failed.

Heroin maintenance has worked in a number of other countries, particularly the Netherlands, and is being considered in Germany, Spain, and Australia.

Surely there's a down side?

A number of criticisms to heroin maintenance have been made, particularly in countries with strict drug laws.
  • Non-addicts may enter the program in order to get free drugs. The extent of this problem remains to be seen, but I personally doubt that there will be a significant number of people willing to try heroin for the first time in a doctor's office.
  • Addicts may abuse the program for free drugs, and continue to use drugs on the side. This could be curtailed with a fairly strict membership requirement; other drugs could be tested for, and membership in the treatment program could be contingent on successful improvement.
  • Heroin maintenance sends the wrong message. The point is that having such a treatment program, particularly a free/subsidized one, suggests that heroin isn't so dangerous, that you can freely try heroin, and if you become addicted, the government will give you heroin for free. In theory, this would increase, rather than decrease, the number of heroin addicts. This is the most difficult point, and the one most politicians will use to shoot down any legalization proposal.

Sources: National Families in Action: http://www.emory.edu/NFIA/legal/heroin/whoheroin.html
Drug Policy Alliance: http://www.drugpolicy.org
Practical Problems of Heroin Maintenance: http://www.drugtext.org/library/articles/praproher.htm