RAND: U.S. should pilot supervised injection sites, heroin-assisted treatment

The rise of fentanyl should drive communities to consider supervised injection sites and other opioid epidemic interventions, according to a new report. (Getty/Irina274)

Positive results from supervised injection sites and heroin-assisted treatment (HAT) abroad suggest it’s time for U.S. policymakers to consider piloting similar programs stateside, according to a new report. 

A new study from RAND Corporation suggests these controversial treatment options are viable for patients with opioid use disorder that’s resistive to traditional medication-assisted treatment (MAT) options like methadone or buprenorphine.

Though boosting access to MAT should be the central priority, RAND’s researchers said that because the opioid epidemic is so widespread—and deadly street drugs like fentanyl are proliferating—it’s important to explore all potential options for addressing the problem. 

“Given where we are with the opioid crisis, and especially with the fentanyl poisoning, in some jurisdictions, you’ll likely be having discussions about other alternatives,” Beau Kilmer, co-director of the RAND Drug Policy Research Center and the study’s lead author, told FierceHealthcare. 

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RAND conducted interviews with teams in Canada and Europe that rolled out either a supervised injection site or HAT. The researchers also interviewed community members, policymakers and addicts in New Hampshire and Ohio—two states hit hard by the opioid crisis—to better gauge the policy landscape for piloting these programs. 

Several randomized clinical trials have been conducted on HAT, and the results indicate that prescribed heroin programs can reduce patients’ risk of criminal activity to maintain their addictions and would mitigate the risk of these patients obtaining fentanyl on the street. 

These trials also found that, though prescribing heroin would cost more than prescribing methadone or buprenorphine, heroin-assisted treatment could be more cost-effective for the specific population that may benefit, in part because it would reduce their likelihood of committing a crime.

However, prescription heroin does carry its own risks, which are greater than those associated with methadone, according to the report. So balancing the potential benefits and risks and being judicious with use is crucial for HAT. 

“This isn’t a first line treatment or a magic bullet,” Kilmer said. “This is an intervention that is intended for those individuals who have been using heroin and who have tried methadone and other treatments but are still injecting.” 

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There is a less-extensive body of literature backing supervised injection sites, according to the report. But many international facilities have been in operation for 15 years or more, which suggests that the benefit is a net positive. 

Discussion on these sites has gained steam in some areas impacted by the opioid epidemic to the degree that Department of Justice Deputy Attorney General Rod Rosenstein wrote an opinion piece in the New York Times criticizing such programs. 

Municipalities or providers that want to roll out either of these programs will run into a number of challenges, according to the report. For one, heroin is a controlled substance under federal law, though there are ways to use it in pilots legally. 

Supervised injection sites would also be illegal, but Kilmer said the federal response could depend on the administration and their interpretation of that law. Legalized recreational marijuana, for example, is also illegal under federal law, but the government hasn’t actively stepped in when states voted to legalize it. 

However, Kilmer said, the first city or state to try a supervised injection site should be prepared for federal backlash, including a court challenge. 

"The federal government reaction to the first one that opens will send a signal to other jurisdictions,” he said.