A new study done for Baltimore's Abell Foundation concludes that programs that give heroin to hard-core addicts can reduce crime and improve public health - findings some hope will spur renewed debate about whether such an effort could help combat the city's unrelenting drug problem.
Peter Reuter, a drug policy expert at the University of Maryland, College Park, analyzed heroin maintenance programs in Switzerland, the Netherlands, Germany and Vancouver, Canada. He found some positive results. In Germany, for instance, participants were less likely to commit crimes, and in Switzerland, many addicts moved from the heroin distribution program to drug treatment aimed at helping them kick their habit.
While Reuter notes there are drawbacks as well - including high costs and low rates of participation - he says public health officials and city leaders should at least discuss the concept.
"It is a sensible innovation to consider," he said. "I am not a passionate advocate for it, but I do think someone should try it in the U.S. It has enough plausibility that it's worth trying."
But the issue raises thorny moral and legal questions and is politically contentious. Baltimore officials call the report unconvincing and say they would not consider the option, especially when proven treatments go underfunded.
"I think it would be a mistake to pursue an expensive and unproven idea when we need more resources for effective drug treatment," said Dr. Joshua M. Sharfstein, the city health commissioner. "There's nothing that persuades me to invest in something that is so expensive and without evidence."
Heroin maintenance programs seek to lure addicts into treatment, not act as a replacement for it, Reuter said. Some researchers believe that once addicts are removed from the drug lifestyle, they can realize the need for help.
Medical professionals treat addicts like patients, distributing doses of heroin in a sterile, clinical setting. In the Netherlands, where the drug is largely smoked, heroin is distributed in small groups. Users remain at the centers while intoxicated but must leave once they have recovered from their dose. In Switzerland, drug users must have failed several treatment options to be accepted into a heroin maintenance program. They also receive weekly counseling sessions and help finding jobs and housing.
Reuter found that the programs helped lead to a modest decrease in crime and spurred some addicts to seek treatment. In Germany, trials done from 2002-2006 measured the average number of days a participant was involved in crime at the start and end of the 12 month program. The average dropped from 15.6 days to 2.5.
In Switzerland, a 2001 study followed up with 2,000 addicts who had left a heroin maintenance program. It found that about 60 percent of them sought treatment. Of those, 60 percent went into a methadone program and 40 percent into an abstinence program.
Reuter says Baltimore's large number of aging addicts might be especially good candidates for heroin maintenance.
Among the programs' shortcomings, he said, is that they enroll a small number of addicts - in Switzerland, just 5 percent of the estimated total. Also, crime declines in the Netherlands were small, not any better than with a good methadone program. Heroin maintenance is expensive and tends to cost more than methadone treatment, Reuter said, though it might reduce health care and other costs in the long run.
Some addiction specialists think Baltimore should at least consider a clinical trial.
"Do I think it would be interesting? In a controlled clinical trial setting, yes," said Susan Sherman, an epidemiologist with the Johns Hopkins Bloomberg School of Public Health "To me, it's also important to have a public dialogue, regardless of the outcome. It forces people to deal with really hard issues about drug use and drug users."
Other addiction specialists agreed that a trial is worthwhile but said adopting such a program might not be feasible.
"Most studies clearly show they help," said Dr. Christopher Welsh, assistant professor of psychiatry at the University of Maryland medical school. "But using public funds to fund something like this would be a whole other level of politics, especially in this economy."
Still, Welsh said heroin maintenance could benefit society in the long run by helping stave off overdoses, HIV/AIDS, hepatitis and serious heart valve infections that come from needle usages. "That can require six to eight weeks in the hospital with antibiotics," he said. "We are paying for that."
But Dr. Peter Beilenson, a former Baltimore health commissioner, said he worries a discussion would sideline practical attempts at reform.
"It's not like everything has been tried and everything has failed and you just throw up your hands," said Beilenson, who is now Howard County's top health official. "The problem is if you are going to do any reasonable drug policy reform, this heroin thing is such a red flag that it takes all the attention away. It makes it look like anyone who is interested in drug policy reform is crazy."
He should know. Eleven years ago, he was blasted for his tacit support for a heroin maintenance research study being considered at Johns Hopkins. He nearly lost his job. The clinical trial never happened. Even his boss, then-Mayor Kurt L. Schmoke, opposed heroin maintenance. A decade earlier, Schmoke had prompted criticism for suggesting that drugs are a public health problem, not a matter of criminal justice.
Looking back, Schmoke said heroin maintenance was worthy of a trial, but he feared it would result in political failure. "Without the kind of discussion that the Abell Foundation is trying to encourage, it would simply be too shocking to the public to get approved."
Beilenson says the issue is still too politically sensitive. "Anyone who even talked about it would be vilified," he said.
Politics isn't the only stumbling block. Legally, the federal government would have to allow heroin to be imported to the U.S. Others believe giving addicts illegal drugs is morally wrong and only serves to further their addiction.
Sharfstein said the cost would not be worth any potential benefit. Rather, treating addicts with methadone and buprenorphine does work, he said. He also took issue with the study's characterization of the city's heroin problem. "We have seen a substantial decline in drug overdoses over the last decade, particularly for heroin; that was not mentioned," he said.
Robert C. Embry Jr., Abell Foundation president, said he isn't advocating for heroin maintenance but that hopes to inform the public on another approach to the heroin problem. "It's a very complicated and difficult question that should be continually discussed and challenged," he said.