A New Treatment for Heroin
Chris Dickey, Medical Writer
Sometime early in 2000, treatment of people with
heroin addiction in the United States will change
radically, according to several experts in the field.
Instead of being forced to go to a clinic nearly
every day, patients with heroin addiction will simply
visit their physician once a month to receive a
prescription for a pill that dissolves under their
"One of the hopes is that individuals addicted to heroin could receive
treatment in mainstream medicine--in the office of their internist," says Dr.
Herbert Kleber of Columbia University.Thus the person in the chair next to
you in your doctor's waiting room may soon be one trying to shed their
addiction to heroin.
"It will essentially change the paradigm of opiate addiction," says Charles
O'Keeffe, president of Reckitt & Colman Pharmaceuticals, Inc., the
manufacturer of one of the new prescribed drugs for heroin addiction. "A lot
of patients who are addicted to opiates are reluctant to enter treatment
because they have not been able to go to a practicing physician in his or
her office. This treatment will allow them to do that."
Two new treatments for heroin addiction are
winding their way through the approval process at
the Food and Drug Administration. The first is called
Subutex and is based on a narcotic called
buprenorphine that acts at the same sites in the
brain as heroin. When buprenorphine is in an
addict's system, heroin has no effect for as many as
2 or 3 days, allowing the body to reduce its powerful
craving for the drug. The second is called Suboxone
and is a combination of buprenorphine and a drug
designed to counter the effects of both heroin and buprenorphine--naloxone.
Who Will Benefit?
There are about 800,000 heroin addicts in the United States, according
Dr. Herbert D. Kleber of Columbia University. Approximately 170,000 are
treated in clinics that administer methadone.
Some of those in treatment will want to be on buprenorphine, but they aren't
the main population that will benefit from the drug's approval for
administration in physician's offices. "It's going to be most useful for those
who aren't in treatment," says Kleber.
Kleber points to three populations in particular who may benefit from the
Citizens of states like Vermont where methadone is not available.
Addicts who are turned off by going to the clinic for a variety of reasons
including loss of anonymity. They may welcome the opportunity to go to the
People who don't like methadone because they may have heard how
difficult it is withdraw from. Buprenorphine may be an easier addiction to
Dr. Frank Vocci of the National Institute on Drug Abuse agrees with Kleber
that there is a potential treatment group of roughly 600,000 addicts in the
United States. "It is reasonable to expect that 25% of that group might one
day be treated either with buprenorphine or the combination of drugs,"
Vocci says. He cautions, "It's not going to happen in the first year."
A New Law
For 25 years the treatment of people with heroin addiction has been
governed by the Narcotic Addict Treatment Act, which sets strict regulations
on the use of narcotics to treat addictions. So far only two narcotic
treatments have been approved for this population--methadone and
levomethadyl acetate (LAAM; brand name Orlaam). Because of the nature
of the Act, these two treatments can only be administered in strictly
"The wording is such that physicians and caregivers
can dispense narcotics to addicts but they may not
prescribe them," says Vocci. "There is legislation
winding its way through Congress now that is meant
to change that." The Drug Addiction Treatment Act
of 1999 recently passed in the US Senate, and is
now on the agenda for the House of
Representatives when they return from winter recess. The new legislation
will allow narcotics treatment for drug addicts to be delivered via a
prescription drug, potentially changing the point of contact for the addict.
Vocci stresses that the legislation does not influence the FDA approval
process. But passage will allow buprenorphine to be prescribed by
selected physicians--ones who treat more than a certain number of addicts
and who apply to the FDA to be allowed to prescribe in this program.
If the person addicted to heroin uses buprenorphine correctly, allowing
dissolve under the tongue, then injected or otherwise ingested heroin will
have no effect: It will be nearly completely blocked by the narcotic effect of
the buprenorphine. Suboxone combines two drugs, one a narcotic and the
other an antinarcotic, on the theory that addicts may try to use
buprenorphine in the same way they are used to using heroin. If the pills are,
for instance ground into a powder and injected, the addict will feel no effect
from the buprenorphine. The effect is essentially blocked by the naloxone.
"Naloxone is 100 times more potent when it is injected than when it is
administered orally," says Kleber. "As long as you take it as directed, your
body doesn't know it's there." An addict who injects buprenorphine might
even go into withdrawal, according to Kleber.
Because of its effect when injected, the addition of naloxone also reduces
the value of the buprenorphine on the street, discouraging addicts from
trying to sell their prescriptions.
Opening the Door
In a speech on the floor of the Senate on November 10, 1999, Senator Orrin
Hatch addressed the need to change the law to allow physicians to
prescribe buprenorphine. "This new system to treat heroin addicts can also
act as a model that can be expanded in the future, as antiaddictive
medications are developed," Hatch said, "to encompass the treatment of
other forms of drug addiction."
"My hope is that we will develop an arsenal of interventions," agrees Kleber,
pointing to the treatment options available to physicians for depression as
an example. "There are a dozen antidepressants out there," he says.
Current Treatments for Heroin Addiction
For the past 30 years, the main treatment for heroin addiction has been
When properly administered, methadone is not intoxicating.
After taking methadone, people can even perform most ordinary
activities--such as driving a car. Methadone reacts with the same
receptors in the brain targeted by heroin, so it relieves much of the
craving associated with heroin withdrawal.
In addition, methadone blocks the effect of heroin, reducing the likelihood
that the addict will continue using the drug while in treatment.
Methadone's effects last for about 24 hours--four to six times as long
those of heroin--so it needs to be taken only once a day. Under FDA
guidelines, according to Dr. Herbert D. Kleber at Columbia University's
Division on Substance Abuse, people with heroin addiction are
compelled to visit the methadone clinic six times a week for the first 3
If they continue to test negative for the presence of heroin after 3 months,
then they begin receiving weekend bottles (five visits per week with a
bottle given out for Saturday and Sunday).
At 6 months the addicts qualify to visit four times per week.
Eventually, after 2 or 3 years, the addict will only visit the clinic once
LAAM and Other Medications
Levomethadyl acetate (LAAM; brand name Orlaam), a longer-acting drug
than methadone, can be used three times a week, reducing the expense
and the problems of daily client visits. A dose of 80 milligrams three times
a week is comparable to 30-100 milligrams of methadone daily.
LAAM, like methadone, is a synthetic opiate that can block the effects
heroin for up to 72 hours with minimal side effects when taken orally. In
1993 the FDA approved the use of LAAM for treating patients addicted to
heroin. LAAM is usually available in clinics that already dispense
Naltrexone is a type of drug known as an opiate antagonist. It blocks the
effects of morphine, heroin, and other opiates. As an antagonist, it is
especially useful as an antidote for heroin overdose. Naltrexone has
long-lasting effects, ranging from 1 to 3 days, depending on the dose, and
it blocks many of the pleasurable effects of heroin. Naltrexone has also
been found to be successful in treating former prisoners who are
"A drug is part of an overall treatment," says Kleber. "It must be given
an appropriate context."
There are many effective behavioral treatments available for heroin
addiction, including residential and outpatient approaches. Several new
behavioral therapies, such as contingency management therapy and
cognitive-behavioral interventions, also show particular promise as
treatments for heroin addiction. Contingency management therapy is a
system based on the use of vouchers: Negative drug tests earn points
that can later be exchanged for items that encourage healthy living.
Cognitive-behavioral interventions are designed to help modify the
patient's thinking, expectancies, and behaviors and to increase skills in
coping with everyday life.