Doctors prescribing heroin? One of two bold moves to curb overdose deaths

In recent years, lawmakers have focused almost exclusively on stopping the flow of illicit fentanyl to combat the opioid overdose crisis. First appearing as a heroin additive in 2012, fentanyl largely replaced heroin in the underground drug market by 2021, driven by COVID-19 supply chain disruptions. Most heroin users “settled” for fentanyl and gradually grew accustomed to the drug. With those disruptions in the rearview mirror, the efficient underground market is responding to consumer demand, fueling heroin’s resurgence.

Tackling heroin and fentanyl addiction is more urgent than ever. Decades of punitive policies under the War on Drugs have cost over $1 trillion and incarcerated millions, yet overdose deaths continue to mount.

In this context, overdose prevention centers and heroin-assisted treatment centers have emerged not as radical ideas but as evidence-based solutions capable of saving lives. These interventions prioritize harm reduction, a pragmatic approach that acknowledges the reality of addiction while striving to mitigate its deadly consequences.

The first government-sanctioned overdose prevention center opened in Bern, Switzerland, in 1986 and continues to save lives. Overdose prevention centers offer safe spaces for drug use under medical supervision. Staffed by health care professionals and equipped with naloxone to reverse overdoses, these centers reduce deaths, improve health care access and decrease public drug use. They also connect individuals to addiction services without fear of punishment, fostering trust and encouraging recovery.

A 2023 Cato Institute study identified 147 government-sanctioned overdose prevention centers operating in 16 high-income countries. Earlier this year, the 148th sanctioned overdose prevention center opened in Providence, R.I. Researchers recently reported in The Lancet on the experience of nine such centers in Toronto, Canada, between 2017 and 2019, finding that overdose fatalities dropped significantly near the centers but not elsewhere.

A complementary but no less controversial harm reduction strategy, heroin-assisted treatment involves administering pharmaceutical-grade heroin under medical supervision. It stabilizes individuals with moderate to severe opioid use disorder who haven’t responded to other treatments, such as buprenorphine and methadone. Also, because fewer than 35 percent of people with opioid use disorder utilize available methadone or buprenorphine programs, there is a significant treatment gap that heroin-assisted treatment can fill.

Studies in Switzerland, Canada and the Netherlands show that heroin-assisted treatment reduces illegal drug use, improves health, decreases criminal activity and fosters social integration. A 2023 systematic review of nine randomized controlled trials in Europe and the U.K. found that heroin-assisted treatment “more consistently retains people with heroin addictions in treatment and reduces their consumption of illicit drugs.”

In Switzerland, for example, participants reported a significant reduction in street heroin use and improvements in health and functioning. Heroin-assisted treatment retention rates — 72 percent for one year and 58 percent for two years or more — clearly outperform more conventional treatments.

Heroin-assisted treatment reduces the chaos and risks of street drug use by offering a lifeline to those navigating a dangerous, fentanyl-saturated market. Unregulated but highly potent fentanyl has made the illegal drug supply more dangerous than ever, with a single gram — equal to a paperclip’s weight — yielding thousands of doses. The lethality of opioids from illicit sources makes a regulated supply of pharmaceutical-grade heroin a life-or-death necessity.

Countries that have embraced overdose prevention centers and heroin-assisted treatment show dramatic public health improvements. In Canada, heroin-assisted treatment participants stayed in treatment and reduced illegal drug use compared to those in methadone treatment. These programs save lives, reduce societal costs, and reduce the strain on emergency services, law enforcement and the judicial system. Fourteen years after Zurich's first heroin-assisted treatment program, Swiss voters approved its continuation in a national referendum.

Traditionally, addiction treatment in the U.S. leaned heavily on well-intentioned but ineffective abstinence-only programs. Critics argue that overdose prevention centers and heroin-assisted treatment encourage drug use and do more harm than good, but decades of data demonstrate the opposite: they reduce street use and improve health outcomes. Newly released position papers by Doctors for Drug Policy Reform offer evidence-based support and recommendations for overdose prevention centers and heroin-assisted treatment.

And more doctors and medical organizations — including the European Monitoring Centre for Drugs and Drug Addiction, the Swiss Federal Office of Public Health and the U.S. National Institute on Drug Abuse — now advocate for overdose prevention centers and heroin-assisted treatment, recognizing them as vital tools in tackling the opioid overdose crisis. This shift — a “man bites dog” moment in public health — reflects growing frustration with the failures of traditional policies and the devastating toll of fentanyl.

Our political leaders must summon the will to remove barriers preventing patients from accessing overdose prevention centers and heroin-assisted treatment. The Drug Administration classifies heroin as a Schedule I (“no currently accepted medical use”) substance, which complicates matters. But state-level initiatives could pave the way for pilot programs, much like cannabis legalization has done. The federal government could support research protocols to evaluate these interventions in the U.S.

We can no longer cling to failed policies prioritizing ideology over human lives. Overdose prevention centers and heroin-assisted treatment provide a proven, science-based approach — one that treats addiction as a medical issue, not a moral failing. With drug overdoses now causing more years of premature death than cancer or heart disease in the United States, delay is no longer an option.

David L. Nathan, MD, DFAPA, is a Princeton, N.J.-based psychiatrist and educator. He is the co-founder and past president of Doctors for Drug Policy Reform, a Distinguished Fellow of the American Psychiatric Association, and a clinical associate professor at Rutgers Robert Wood Johnson Medical School. Jeffrey A. Singer, MD, FACS, practices general surgery in Phoenix, Ariz., and is a senior fellow at the Cato Institute.