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Consultation Document on Opioid Agonist Treatment
3. Discussion:
A. The Scope of the Problem:
Although a relatively small percentage of America's illegal drug users use heroin, the debilitating addictive effects of the drug make it one of the major sources of drug-related health, crime, and social costs. ONDCP estimates a population of 810,000 chronic heroin users in the United States in 1995.
| (1) Trends—High Purity: While the number of new heroin initiates is still relatively low, it is apparent that the availability of high-purity heroin has led to an increase in use, probably related to changes in the route of administration. High purity heroin can be snorted, smoked, or otherwise inhaled, and need not be injected. Heroin users who have snorted or smoked heroin increased from 55 percent of heroin users in 1994 to 82 percent in 1996. This trend is disturbing in two aspects: first, because it expands the use of heroin to those who might be reluctant to initially inject heroin; and, second, because heroin can now be ingested using the same "pathway" as other commonly abused substances such as tobacco, crack, and marijuana. The ability to snort or smoke heroin is likely to foster experimentation, adding to the numbers of users and leading to injection for many of them over time. The Drug Abuse Warning Network (DAWN) reports that, prior to its decline in early 1997, the number of persons seeking treatment in hospital emergency rooms and citing heroin use increased by 78 percent between 1994 and 1996. Most of these patients sought detoxification or medical treatment to deal with overdose or the chronic effects of heroin use.
(2) Trends—Heroin Addicts and Other Chronic, Hardcore Drug Users are Undercounted: Because of the nature of heroin abuse, many chronic users may not be captured by traditional measures such as the Household Survey (which only surveys those living in households) and Monitoring the Future (which only counts youth enrolled in school). ONDCP sponsored a pilot research study in Cook County, Illinois, which sought to gauge the number of chronic drug users in a major urban area by interviewing heroin and cocaine addicts who were arrested, seeking drug abuse treatment, or living in homeless shelters. The results of this study determined that there were three times the number of hardcore addicts in Cook County than indicated by the Household Survey. These results suggest that the actual number of chronic heroin users in the United States may be much larger than previously thought.
(3) Trends—The Population of Addicts is Aging, Even as Younger Initiates Increase: Many heroin addicts only encounter serious health problems after years of abuse. One disturbing trend is that heroin addicts who began use in the last great heroin epidemic of the late 1960s and early 1970s are now requiring increased degrees of medical care for the cumulative debilitating effects of their abuse. Since 1978 the number of emergency room mentions for heroin among those aged 35 and older has tripled. The DAWN report of drug abuse mentions in hospital emergency departments shows that heroin/morphine mentions (which overwhelmingly refer to heroin) have increased from 17.5 per 100,000 population in 1988 to 30.4 per 100,000 in 1995 and 31.4 per 100,000 in 1996. The largest rates of increase in heroin mentions, however, are seen among youth ages 12 to 17 and users aged 18 to 25. The mean age of initiation for heroin dropped from 26.2 years in 1988 to 18.1 in 1996.
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B. The Implications of the Problem:
Heroin users are at risk for many of the social and public health dangers associated with drug abuse.
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(1) Heroin is a toxic substance: The danger of a fatal overdose is more immediate and likely for a heroin user than for users of other common drugs of abuse because of the route of ingestion and common miscalculations of dosage. Misjudging heroin purity can have fatal implications. The National Institute of Drug Abuse has declared that heroin is a powerfully addicting substance producing tolerance, physical dependence, and the clinical state of addiction (defined as compulsive, often truly uncontrollable drug craving, seeking, and use). Typically, heroin use is involved in about 15 percent of all drug-related emergency room visits—a number that far exceeds the proportion of heroin users in the general drug-using population.
(2) Heroin use is associated with crime: Because of the addictive and tolerance properties of heroin use, users in the early stages of their drug using career find that they need heroin frequently in increasing doses. Because the withdrawal effects of heroin are both severe and frequent, heroin users typically use heroin several times a day. The need to purchase large amounts of a costly drug inevitably leads to crime. For decades some cities have estimated that over half of all property crime is attributable to heroin use. Twenty percent of all people arrested in Manhattan in 1997 tested positive for opiates. In the same year, 22 percent of all arrestees in Chicago tested positive for opiates.
(3) Heroin use affects public health: There is a strong nexus between heroin use and many life-threatening communicable diseases, including infections such as hepatitis B and C, HIV/AIDS, and endocarditis; as well as tuberculosis and sexually transmitted diseases (especially as they relate to pregnancy outcomes). The eroin subculture—with its sharing of needles and "cooking equipment" and associated high-risk sexual behaviors and prostitution (sex for drugs)—is a major factor in the spread of such diseases. The Centers for Disease Control (CDC) estimates injecting drug users (most of whom are heroin users) account for between 15 and 36 percent of the nation's new HIV infections each year. According to CDC's HIV/AIDS Surveillance Report, of 13,111 new HIV cases reported between July 1996 and June 1997, injecting drug use was an "exposure category" for over 2,200. Heroin users are also associated with violent crime. Heroin use not only undermines the health of the user, but
also—in the case of pregnant women—can seriously affect the health of their children. |
C. Heroin addiction is difficult to overcome: The psycho-pharmacological effects of heroin are extremely strong. Satisfaction of the self-destructive need becomes nearly a full-time occupation. Heroin addicts spend a large amount of their time searching for drugs. An ONDCP study of cocaine, crack, and heroin abuse in six cities found that the percentage of heroin users who used heroin for 30 or more consecutive days over a 90 day period was four times greater than the percentage for crack and powder cocaine users. This finding indicates that there is a high proportion of heroin addicts among the users of heroin. Cessation of heroin use is difficult: the same study found that heroin users reporting 30 or more consecutive days of abstinence in a 90 day period tended to be lower than for crack or powder cocaine users. The relatively stable number of heroin addicts over the years, particularly in older age groups, indicates the relative lack of effective treatment capacity and aggressive outreach programs to get the addicts into treatment. In some cities, an entire heroin culture that spans generations has evolved, as addicts cycle through the criminal justice system and back into street addiction without any prospect of entering an effective treatment regimen.
D. Methadone—a widely accepted modality: Methadone has been used for the treatment of heroin addiction since the 1960s. It is a synthetic agonist agent for opiates. In other words, methadone operates by "occupying" the brain receptor sites that are affected by heroin and blocks the craving attendant to addiction. Eventually it produces tolerance to its own analgesic effects and also produces a physiological cross-tolerance to other opiates. Because withdrawal from methadone is slower than from heroin, it is relatively easy to maintain an addict on methadone without abrupt side effects. Initially, methadone was used in the context of abstinence-based drug treatment to alleviate withdrawal pains for heroin addicts.
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(1) The rise of methadone treatment: Heroin addiction became a major public concern due to the epidemic of the 1960s. The growth in heroin addiction came in the context of a major shift in public health approaches towards addiction which shifted away from an (often coercive) in-patient treatment regimen to an out-patient, community-based approach. Confronted with a rising number of heroin addicts and faced with a choice between methadone treatment and other treatment regimes which promised uncertain results at the time, many governmental agencies opted to pursue methadone treatment. The American Bar Association noted in a 1972 report that New York City had 18,072 people in methadone programs, with a waiting list of 15,000 more, and that 65 percent of all participants in New York City treatment programs were in methadone treatment. National estimates of the number of patients in methadone treatment indicated growth through 1993, with an estimate of 81,852 in methadone treatment in 1987, nearly 95, 300 in 1991, and 117,000 in 1993. Recently, methadone treatment capacity has declined, with 115,000 patients estimated as receiving methadone treatment in each of the last two years.
(2) Methadone treatment today: Methadone treatment is the most widely used treatment for heroin addiction today. It has been studied more than any other drug treatment modality, with uniformly positive results. Over 115,000 Americans are able to lead stable lives as a result of methadone treatment. Over 900 methadone treatment programs in America provide an invaluable service. The National Institute on Drug Abuse (NIDA) has conducted literally dozens of studies which show the effectiveness of methadone treatment. The Drug Abuse Treatment Outcome Study (DATOS), the most recent study by NIDA, found that among participants in outpatient methadone treatment, weekly heroin use decreased 69 percent, cocaine use by 48 percent (many heroin users are polydrug users), illegal activity decreased 52 percent, and full time work increased by 24 percent. Methadone treatment, at an average cost of $13 or less per day, is a cost effective alternative to incarceration. In spite of this proven track record, methadone treatment capacity has not experienced marked growth. Treatment capacity is insufficient to provide most of the 810,000 heroin addicts with methadone treatment or any other effective form of drug abuse treatment. In 1995, the Institute of Medicine identified ten states in which methadone treatment was not available at all: Arkansas, Idaho, Maine, Mississippi, Montana, North Dakota, New Hampshire, South Dakota, Vermont, and West Virginia.
(3) Criticisms of methadone treatment: The full benefits of methadone treatment are only obtained within a comprehensive treatment environment, which screens and evaluates patients and assigns them to treatment regimes based upon the nature of each patient's addiction. Programs must evaluate their use of methadone and assess methadone's utility for each patient at regular intervals. However, such discipline has not universally been the case. A 1990 GAO report based on observations of 24 methadone treatment organizations found that policies, goals and practices varied greatly and that not one of the programs studied evaluated the effectiveness of their treatment. The failures of the unsuccessful programs tarnished the entire idea of methadone treatment, rather than spurring efforts to improve the delivery of services. |
Last Updated: March 4, 2002
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