THERE MIGHT BE NEW HOPE IN THE TREATMENT OF HEROIN ADDICTS

Opiate Pain Killer Hydromorphone Doesn't Carry the Esthetic Negative
Baggage of Heroin and Is Already Licensed for Use

The sorry fact about drug policy is that esthetics matter.

Heroin, for example, is seen as a dirty drug taken by dirty people,
unkempt down-and-outers writhing in agony and angst on skid row.
Methadone, on the other hand, is a pharmaceutical preparation
distributed by people wearing white coats in the antiseptic wards of
hospitals and medical clinics.

These vastly different esthetics help to explain why we have treated
heroin addicts with methadone for decades, while prescribing heroin
remains highly controversial. But it wasn't always so.

In the 19th and early 20th centuries, North American physicians often
treated their heroin-addicted patients -- and themselves -- with
heroin, recognizing as they did that addicts could live productive,
healthy lives while being prescribed heroin.

That all changed in the 20th century, when Canada, followed by the
United States, criminalized heroin for reasons that had little to do
with the properties of the drug. Britain, in contrast, continued
heroin maintenance, with conspicuous success, until the late 1960s,
when political interests led to its elimination.

The result of criminalization in all three countries was predictable:
The black market filled the void, and heroin became a dirty drug used
by dirty people. Methadone, despite being an addictive opiate, became
the drug of choice for treating addicts, in part because it enjoyed a
more positive image. Yet we've known for some time that methadone
doesn't work for everyone. Studies in several European countries
confirmed that prescribing heroin to hard-to-treat heroin addicts
resulted in improved physical, emotional and social functioning, and
lowered the rate of criminal behaviour among addicts.

The North American Opiate Medication Initiative (NAOMI) trial, whose
results have just been published in the New England Journal of
Medicine, largely replicated the findings of the European studies.
The randomized controlled trial assigned hard-to-treat subjects in
Vancouver and Montreal to two groups: One group received oral
methadone, while the other received injectable diacetylmorphine, the
active ingredient in heroin.

Members of both groups benefited from treatment, but those in the
diacetylmorphine group did significantly better: After 12 months, 88
per cent remained in treatment, compared to 54 per cent in the
methadone group. Similarly, the diacetylmorphine group experienced a
67-per-cent reduction in involvement in illegal activities, including
use of illicit drugs, while illegal behaviour in the methadone group
decreased by 48 per cent.

Now, since hard-to-treat addicts typically suffer from, and cause,
the most serious problems, heroin-assisted treatment might well save
their lives, and save everyone else a lot of trouble -- and money.
But whether such treatment becomes a reality depends in part on
esthetics -- on whether heroin can shed its bad-boy image. In other
words, to rehabilitate heroin addicts, we must first rehabilitate heroin.

The NAOMI trial should help, though so far things don't look
promising: Investigators were refused government permission to
continue prescribing heroin to study subjects, which has led to the
deterioration of many who prospered during the trial.

But there is a bright spot: A small group of 25 NAOMI subjects were
given injectable hydromorphone (Dilaudid) -- an opiate pain reliever
- -- to determine whether they were using street drugs during the
trial. Interestingly, the investigators found hydromorphone was just
as effective as heroin at treating addiction.

However, given the small sample size, there is insufficient
statistical power to draw any firm conclusions about hydromorphone's
relative effectiveness. The next phase of NAOMI -- the Study to
Assess the Longer-term Opiod Medication Effectiveness, or SALOME --
will investigate precisely this issue.

If it's found effective, hydromorphone could relieve us of the need
to give heroin a make-over, since it doesn't carry the negative
esthetic baggage of heroin and is already licensed for use. Moreover,
it could open the door to the 19th century -- to a wiser time when
heroin addiction was treated in clinics instead of courthouses.