Drug substitution and maintenance approaches have a long history of providing individuals struggling with addiction with legal access to drugs that would otherwise be obtained through illegal means.  The basic rationale is harm reduction: if some people are unable to quit using drugs, both users and society at large benefit if they are able to switch from "black market" drugs of indeterminate quality, purity and potency to legal drugs, of known purity and potency, obtained from physicians, pharmacies and other legal channels.  The risks of overdoses and other medical complications decline; the motivation and need for addicts to commit crimes to support their habits drop; addicts are more likely to maintain contact with drug treatment and other services, and more able and likely to stabilize their lives and become productive citizens.

While maintenance clinics in the United States date back to the beginning of the 20th century, they saw renewed popularity in the 1960’s with the advent of methadone, a synthetic morphine substitute discovered by German scientists during World War II.  Methadone maintenance is now widely regarded as the most effective known treatment for heroin addiction. Used properly, methadone reduces drug use and related crime, death, and disease among heroin users.  But methadone has been handicapped by restrictive government regulations, by misinformation - among treatment providers and drug users alike - and by prejudice against methadone treatment.  Methadone is the most tightly restricted drug in the U.S.  Doctors in general medical practice can't prescribe methadone, and regular pharmacies don't distribute it.

For drug users who have not found success with methadone, the most dramatic developments in drug substitution therapies have been in the field of Heroin-Assisted Treatment (HAT).  HAT programs, as part of comprehensive treatment strategies, provide substantial benefits to long-term heroin users who have not been responsive to other treatment.  Nearly all studies have shown that those enrolled in HAT demonstrate a reduction in substance use and an improvement in overall physical and mental health.  Additionally, several studies have found that individuals who participated in these programs significantly reduced their involvement in criminal activities, generating large cost savings.  Although each of the studies differed in target population, methodology and other factors, the consistent, positive results strongly suggest that heroin maintenance may be a feasible, effective and cost-effective strategy for reducing drug use and drug-related harm among long-term heroin users for whom other treatment programs have failed.

HAT trials have now been conducted in 6 countries (Switzerland, the Netherlands, England, Spain, Germany and Canada) with positive results. Two of these countries (Switzerland and the Netherlands) have integrated HAT into their drug treatment arsenal, and the German parliament has recently voted to move forward with the treatment, as well. Denmark will start providing HAT at the end of 2009 after the government decided that data from existing trials are strong enough to move forward without going through its own trial phase.

Additional Resources:

• Heroin Assisted Treatment Timeline
• Heroin Assisted Treatment FAQs
• Heroin Assisted Treatment Fact Sheet
• Heroin Assisted Treatment Annotated Bibliography