It’s almost as firm a rule as medicine has – “Don’t give addictive substances to addicts.” The principle flows from the “First, do no harm” dictum. If the addiction is causing harm, then prescribing an addictive substance will support that harm. However, there are exceptions.
If the purpose of giving the addictive substance is to mitigate withdrawal – lessening the acute effects – so you can wean a patient off a substance, then it is permissible. This is one way to fight severe alcohol withdrawal and the life threatening consequences. By giving some alcohol and then gradually reducing the dose, the patient can have a smoother and safer withdrawal. But the end result is to get them off, in this case, alcohol.
This same rule has been followed with methadone treatment and heroin addiction. Patients who receive methadone, which is highly addictive, are supposed to be counseled and helped to kick both methadone and heroin. So even here, the idea is to get them off the opiates.
But a study out of Canada shows that for one class of patient, it might be best to supply them with heroin and skip the methadone altogether, at least on the dimension of lowered cost and societal harm.
That second measure, societal harm, uses a combination of costs: the cost of the drug used to maintain the addiction, the cost of treatment with or without giving the addictive substance, and the cost to society (families, employment, legal). This extends the “do no harm” into a larger realm – which method does less harm in the big picture?
The class of patients getting heroin (instead of methadone) are called refractory. This means a patient for whom we’ve tried the usual menu of treatments and haven’t had any success. The researchers aren’t suggesting that all heroin addicts get medically supplied heroin. After rehab and after methadone maintenance therapy fail, only then does the idea of giving heroin to heroin addicts cost less than letting them loose to find their own way on the streets.
While the study was done in Canada, it has ramifications for the US as well. In a time when both the public and the medical community are reexamining illegal drugs for medical purposes, it may be that providing heroin in specific, limited circumstances will catch on.