Revenue and Economic Development Committee Hearing on Senate Bill

No. 275
Testimony of Ethan Nadelmann, Executive Director, Drug Policy Alliance
April 7, 2015
Good afternoon. I am Ethan Nadelmann, Executive Director of the Drug
Policy Alliance, the nations leading organization advocating alternatives to
the failed war on drugs. I want to thank the Revenue and Economic
Development Committee for the opportunity to address you today and submit
written testimony in favor of the heroin-assisted treatment pilot project that
SB275 would create.
The evidence is in. Heroin-assisted treatment, also known as heroin
maintenance, is a feasible, effective, and cost-saving strategy for reducing
drug use and drug-related harm among long-term heroin users for whom other
treatment programs have failed.1 Permanent heroin maintenance programs
have been established in the United Kingdom, Switzerland, the Netherlands,
Germany, and Denmark, with additional trial programs having been
completed or currently taking place in Spain, Belgium, and Canada.2 Findings
from randomized controlled studies in these countries have yielded
unanimously positive results.3 Heroin-assisted treatment is associated with
decreased illicit drug use, crime, overdose fatalities, and risky injecting, as
well as significant improvements in physical and mental health, employment,
and social relations.4 Given the consistently positive results, heroin-assisted
treatment is not as controversial or radical as it may seem at first blush.
Rather, it is a treatment modality that has gained traction within the scientific
community as a tried-and-true method for dealing with particularly refractory
cases of heroin addiction and the associated harms.
I would like to first highlight the development and history of heroin-assisted
treatment in other countries and review the compelling evidence base that has
been amassed from the international experience before contextualizing the
importance of SB275 within our own country and this state.
TIMELINE AND DEVELOPMENT OF HEROIN-ASSISTED
TREATMENT IN OTHER COUNTRIES
Though heroin has been available by individual prescription in the United
Kingdom since 1926,5 Switzerland opened the first supervised heroin-assisted
treatment centers as part of a clinical study in 1994.6 In 1999, after reviewing
the initial positive results of the Swiss study, the World Health Organization
recommended more randomized clinical trials on heroin maintenance.7
Between 2002 and 2010, the Netherlands,8 Spain,9 Germany,10 Canada11 and
the United Kingdom12 published the results of additional studies showing that

Board Members
Larry Campbell
Christine Downton
Jodie Evans
James E. Ferguson, II
Jason Flom
Ira Glasser
Carl Hart, PhD
Mathilde Krim, PhD
David C. Lewis, MD
Pamela Lichty
Ethan Nadelmann, JD, PhD
Josiah Rich, MD
Rev. Edwin Sanders
Michael Skolnik
George Soros
Ilona Szab de Carvalho
Richard B. Wolf
Honorary Board
Former Mayor
Rocky Anderson
Harry Belafonte
Richard Branson
Former Defense Secretary
Frank C. Carlucci, III
Deepak Chopra
Rep. John Conyers, Jr.
Walter Cronkite
[1916-2009]
Ram Dass
Vincent Dole, MD
[1913-2006]
Former President of the Swiss
Confederation Ruth Dreifuss
Former Surgeon General
Joycelyn Elders
Judge Nancy Gertner (Ret.)
Former Police Chief
Penny Harrington
Former President of the
Czech Republic Vclav Havel
[1936-2011]
Calvin Hill
Arianna Huffington
Former Governor
Gary Johnson
Judge John Kane
Former Attorney General
Nicholas deB. Katzenbach
[1922-2012]
Former Police Chief
Joseph McNamara
[1934-2014]
Former Police Commissioner
Patrick V. Murphy
[1920-2011]
Benny J. Primm, MD
Dennis Rivera
Former Mayor Kurt Schmoke
Charles R. Schuster, PhD
[1930-2011]
Alexander Shulgin, PhD
[1925-2014]
Former Secretary of State
George P. Shultz
Russell Simmons
Sting
Judge Robert Sweet
Former Chairman of the Federal
Reserve Paul Volcker

heroin is more effective than oral methadone for people who have not
benefitted from standard treatments. By 2010, heroin was registered for
maintenance treatment in the United Kingdom, Switzerland, The Netherlands,
Denmark, and Germany.13
The Dutch government supported the rollout of heroin maintenance as regular
addiction treatment alongside other existing interventions in 2004 and, in
December 2006, the Dutch Medicines Evaluation Board approved both
inhalable and injectable heroin as a medicinal product for maintenance
treatment.14 As of July 2011, 650 patients receive heroin-assisted treatment in
17 clinics throughout the country.15 In Switzerland, a national referendum to
permit heroin maintenance passed with 68% of the public vote in 2008.16
There are now 23 facilities in Switzerland providing heroin-assisted treatment,
including two located in prisons, serving nearly 1,500 people.17 Though
Denmark never hosted a clinical trial, the government approved a proposal to
allow heroin-assisted treatment in 2008 based on the overwhelming evidence
from other countries.18 Five heroin maintenance clinics now serve an
estimated 300 people.19 Germanys parliament voted to allow heroin-assisted
treatment in 2009 and it is now available in nine clinics serving approximately
500 patients throughout the country.20 In the United Kingdom, three clinics
remained open after the conclusion of their trial program and currently serve
approximately 100 people.21 In January 2012, the government gave approval
for the roll-out of additional heroin maintenance clinics after the Department
of Health concluded that heroin-assisted treatment is now evidenced as a
clinically-effective second-line treatment . . . .22 Moreover, approximately
500 people in the United Kingdom receive prescription heroin directly from
their physician for maintenance treatment.23
In addition to permanent treatment programs, trial programs are currently
operating in Canada (a second study began in 2011)24 and Belgium (also
began in 2011).25 Luxembourg is considering the implementation of similar
trials.26
KEY RESEARCH FINDINGS
Results from the European and Canadian trials and permanent programs
demonstrate that prescribed pharmaceutical heroin does exactly what it is
intended to do: it reaches a treatment refractory group of addicts by engaging
them in a positive healthcare relationship with a physician, it reduces their
criminal activity, improves their health status, and increases their social tenure
through more stable housing, employment, and contact with family.27
Moreover, these substantial benefits come with improved cost-savings
compared to standard treatments28 and with no negative impacts on the larger
community.29

Heroin Maintenance is Cost-Effective

Though heroin-assisted treatment is initially more expensive than standard
treatment modalities such as methadone, the up-front expense is more than repaid with significant societal savings due to, among other factors, reduced
medical and law enforcement costs.30 A cost-benefit analysis of the Swiss
program showed the benefits of heroin maintenance per day amounted to
twice the daily treatment costs.31 It is estimated that heroin-assisted treatment
saves approximately 12,000 euros per patient per year in the Netherlands,32
9,000 dollars per patient per year in Switzerland,33 and 6,300 euros per patient
per year in Germany,34 compared to methadone maintenance.
Heroin-Assisted Treatment Reduces Crime
Researchers in Spain,35 England,36 Switzerland,37 and Germany38 have
reported significant reductions in crime among heroin maintenance
participants. The Swiss heroin treatment group, for example, showed
significant reductions in criminal charges compared to the methadone
maintenance group, including charges for drug use and/or possession (11% vs.
38%), property theft (4% vs. 24%), and other offense/charge in the prior six
months (19% vs. 57%).39 The German trial also reported that participants in
the heroin maintenance group engaged in criminal activities less often than
those in the methadone group, with fewer reported days of crime against
property (10.3 vs. 37.5), less frequent arrests (2.1 vs. 2.8 times a year), and
less frequent convictions (0.25 vs. 0.54 times).40 Another German study
found that the percentage of individuals who had committed at least one
offense in the respective year dropped from 79% to 45% in the heroin group
compared to 79% to 63 % in the methadone group.41 Similarly, the average
number of offenses also declined in the heroin group from 76.7% to 26.8%a
significantly greater drop than the methadone group, where it only declined to
49%.42
Heroin-Assisted Treatment Reduces Drug Use
Every heroin-assisted treatment trial has shown a marked decrease in street
heroin use.43 A Cochrane systematic review concluded that [e]ach study
found a superior reduction in illicit drug use in the heroin arm rather than in
the methadone arm . . . the measures of effect obtained are consistently
statistically significant.44 The United Kingdom trial, for instance, reported
over a two-thirds (72 percent) reduction in illicit drug use among heroinassisted treatment participants.45 Similar reductions in street heroin use were
reported from heroin maintenance trials in Switzerland (74 percent),46
Germany (69 percent),47 and Canada (67 percent).48 Heroin-maintenance
patients also experience less (and less severe) cravings, helping to explain
their decreased use.49 Heroin-assisted treatment has also demonstrated an
added benefit of reducing participants use of alcohol and other drugs.50

Retention Rates in Heroin-Assisted Treatment Surpass Those of

Conventional Treatment
Studies consistently demonstrate that retention rates in heroin-assisted
treatment are high. The Swiss trial found that 93% of patients remained in
treatment at 12 months, 50% at 3.3 years, and 30% at the six-year mark.51
Moreover, some studies have found that patients who have failed other
treatments stay in heroin maintenance programs significantly longer than their
counterparts who only receive methadone. Retention rates in the Canadian
trial at 12 months were 87.8% for those receiving heroin-assisted treatment
versus 54.1% for the control group receiving methadone.52 In the German
study, retention at 12 months was also higher in the heroin maintenance group
than in the methadone group (67 % vs. 40 %).53
Heroin Maintenance Can Be a Stepping Stone to Other Treatments and
Even Abstinence
While retention rates are high, the majority of patients who do discontinue
treatment do not relapse. Rather, results from studies of heroin-assisted
treatment have undermined several myths about heroin and its habitual users:
given relatively unlimited availability, heroin users will voluntarily stabilize
or reduce their dosage or switch to other treatments, and some will even
choose abstinence. Indeed, the Swiss study found that more than 60 percent
of those who exited heroin maintenance did so in order to take up another
treatment option.54 The majority of those seeking other treatment went into a
methadone maintenance program, but almost 40 percent went into an
abstinence program.55
Heroin-Assisted Treatment Improves Health, Social Functioning, and
Quality of Life
All published studies that have examined the question have reported that
patients in heroin-assisted treatment see improvements on measures of
physical and mental health, including better nutritional status, cardiac
function, and body-mass index as well as lower overdose and infectious
disease rates.56 Researchers in Germany found that health improvements were
seen as early as the first few months of treatment but became more
pronounced as time in treatment increased.57 Moreover, studies have found
that quality of life improves significantly for those in heroin-assisted
treatment. The Swiss trial demonstrated long-term improvement in reduced
proportions of patients with an unstable housing situation (baseline: 43% vs.
18 months: 21%), homelessness (baseline: 18% vs. 18 months: 1%),
unemployment (baseline: 73% vs. 18 months: 45%) and those receiving
welfare payments (baseline: 63% vs. 18 months: 54%).58 Marked
improvements in the social domain were also evident in the German trial with

a significantly higher proportion of patients in stable housing (baseline: 76%

vs. 24 months: 91%) and stable jobs (baseline: 15% vs. 24 months: 26 %).59
Heroin Maintenance Does Not Pose Nuisance or Other Neighborhood
Concerns
Two community impact studies evaluating the establishment and operation of
heroin-assisted treatment clinics have found that they do not result in any
negative impacts, such as changes in street public nuisance or amount of
criminal offenses, for those residing and working in surrounding areas.60 In
Canada, no impact was detected of either the introduction of the heroin
maintenance clinics or the increase in the number of attending patients on the
number of violent or property crimes or acts of public disorder committed in
the clinic vicinity.61 In the United Kingdom, Metropolitan Police figures
revealed no significant changes in monthly or average annual crime levels in
the areas where treatment centers were located over the two-year trial
period.62
Heroin-Assisted Treatment Can Reduce the Black Market for Heroin
Though heroin-assisted treatment programs only serve a small minority of the
population that uses heroin, it is this subgroup that consumes the majority of
the heroin supply. For this reason, heroin maintenance can actually help
destabilize local heroin markets. One published article concluded that heroin
maintenance participants accounted for a substantial proportion of
consumption of illicit heroin, and that removing them from the illicit market
has damaged the markets viability.63 The authors further state that by
removing retail workers [who] no longer sold drugs to existing users, and . . .
no longer recruited new users in to the market . . . the heroin prescription
market may thus have had a significant impact on heroin markets in
Switzerland.64
HEROIN-ASSISTED TREATMENT IN NEVADA
A scientifically proven treatment, the efficacy of which is virtually
unquestioned, remains unexamined and unutilized in the United States
because domestic policy fails to recognize and treat drug use as a health issue.
But we cannot arrest or incarcerate our way out of a chronic disease like
heroin addiction. The failed war on drugs has proved as much. Illicit drug
use in America has been steadily increasing despite our punitive policies.65
Approximately 156,000 new people started using heroin in 2012, nearly
double the number of people in 2006.66 Moreover, the number of people
meeting the Diagnostic and Statistical Manual of Mental Disorders criteria for
dependence or abuse of heroin doubled from 214,000 in 2002 to 467,000 in
2012.67 Nevada echoes these national trends and ranks tenth in the nation in
illicit drug use rates.68 Statistics from the Division of Public and Behavioral

Health show heroin deaths in Nevada have doubled in recent years.69 A

number of local news reports have indicated that treatment providers and law
enforcement are seeing a significant rise in heroin use and heroin seizures in
Nevada.70 In short, we are confronted in this state, and the nation at large,
with a growing and serious heroin epidemic. We cannot continue to rely on
the same strategies and expect a different result. Politics can no longer trump
science - and compassion, common sense, and fiscal prudence - in dealing
with and addressing drug use and abuse.
The results from well-designed randomized controlled trials, which have been
peer reviewed and published in high-impact scientific journals, as well as
steadily accumulating clinical experience can inform the successful
development and implementation of a heroin-assisted treatment program in
Nevada that will reach the most marginalized and hard-to-treat heroin users.
Such a program will undoubtedly result in significant health, safety, and cost
benefits for your state. But passing SB275 would also do significantly more
than that. It would represent a significant paradigm shift in how we address
and treat drug addiction in the United States. Nevada has the opportunity to
serve as a model for treating drug use as what it isa health issue that should
be combated with evidence-based, rigorously studied treatments with proven
benefits for the users, their families, and the community as a whole. I
sincerely hope you will make the most of the opportunity before you.
Thank you, again, for the opportunity to submit testimony on this
groundbreaking legislation.
Sincerely,

Ethan Nadelmann
Executive Director

Lindsay LaSalle
Staff Attorney

See, e.g., Fischer, B., Oviedo-Joekes, E., Blanken, P., et al. (2007). Heroin-assisted
treatment (HAT) a decade later: A brief update on science and politics. J Urban Health, 84,
552-62.
2
Strang, J., Groshkova, T. & Metrebian, N. (2012). New heroin-assisted treatment: Recent
evidence and current practices of supervised injectable heroin treatment in Europe and
beyond. European Monitoring Centre for Drugs and Drug Addiction Insights. Luxembourg:
Publications.
3
See, e.g., van den Brink, W., Hendricks, V. M., Blanken, P., et al. (2003). Medical
prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials.
British Medical Journal, 327, 310316; Haasen, C., Verthein, U., Degkwitz, P., et al. (2007).
Heroin-assisted treatment for opioid dependence. British Journal of Psychiatry, 191, 5562;

March, J. C., Oviedo-Joekes, E., Perea-Milla, E., Carrasco, F. et al. (2006). Controlled trial of
prescribed heroin in the treatment of opioid addiction. Journal of Substance Abuse Treatment,
31, 203211; Oviedo-Joekes, E., Brissette, S., Marsh, D., et al. (2009). Diacetylmorphine
versus methadone for the treatment of opiate addiction. The New England Journal of
Medicine, 361, 777786; Perneger, T. V., Giner, F., del Rio, M. & Mino, A. (1998).
Randomised trial of heroin maintenance programme for addicts who fail in conventional drug
treatments. British Medical Journal 317, 1318; Strang, J., Metrebian, N., Lintzeris, N., et al.
(2010). Supervised injectable heroin or injectable methadone versus optimised oral
methadone as treatment for chronic heroin addicts in England after persistent failure in
orthodox treatment (RIOTT): a randomised trial. Lancet, 375, 18851895.
4
See, e.g., Ferri, M., Davoli, M., & Perucci, C.A. (2005). Heroin maintenance for chronic
heroin dependents. Cochrane Database Syst Rev., 2.
5
Metrebian, N., Carnwath, Z., Mott, J., Carnwath, T., Stimson, G.V., Sell, L. (2006). Patients
receiving a prescription for diamorphine (heroin) in the United Kingdom. Drug Alcohol Rev,
25, 115-21.
6
Rehm, J., Gschwend, P., Steffen, T., Gutzwiller, F., Dobler-Mikola, A. & Uchtenhagen, A.
(2001). Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid
addicts: a follow-up study. Lancet, 358, 1417-23.
7
Ali, R., Auriacombe, M., Casas, M., Cottler, L., Farell, M., Kleiber, D., Kreuzer, A.,
Ogborne, A., Rehm, J. & Ward, P. (1999). Report of the external panel on the evaluation of
the Swiss scientific studies of medically prescribed narcotics to drug addicts. Geneva: WHO.
8
van den Brink et al. (2003), supra note 3.
9
March, J.C. et al. (2006), supra note 3.
10
Haasen et al. (2007), supra note 3.
11
Oviedo-Joekes et al. (2009), supra note 3.
12
Strang et al. (2010), supra note 3.
13
Strang et al. (2012) supra note 2 at 19, 25.
14
Blanken, P., van den Brink, W., Hendriks, V. M., et al. (2010). Heroin-assisted treatment in
the Netherlands: History, findings, and international context. European
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15
Strang et al. (2012), supra note 2 at 149.
16
Id. at 103.
17
Strang et al. (2012), supra note 2 at 104.
18
Id. at 145.
19
Id. at 147.
20
Strang et al. (2012), supra note 2 at 126.
21
Id. at 138.
22
Id. at 143-44.
23
Lintzeris, N., Strang, J., Metrebian, N., et al. (2006). Methodology for the Randomised
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24
Providence Health Care, Salome,
http://www.providencehealthcare.org/salome/outcomes.html.
25
Demaret, I., Hern, P., Lematre, A. & Ansseau, M. (2011). Feasibility assessment of
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26
Ferri et al. (2005), supra note 4.
27
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28
Bammer, G., van den Brink, W., Gschwend, P., et al. (2003). What can the Swiss and
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29

Lansier, B., Brochu, S., Bovd, N. & Fischer, B. (2010). A heroin prescription trial: Case
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supervised injectable maintenance clinic in south London. Mental Health and Substance Use:
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30
Bammer et al., supra note 28; Dijkgraaf et al. (2005), supra note 28.
31
Bammer, supra note 28.
32
Dijkgraaf et al. (2005), supra note 28.
33
Brehmer, C. & Hen, P.X. (2001). Medical prescription of heroin to chronic heroin addicts
in Switzerland - a review. Forensic Science International, 121, 23-26.
34
Haasen, C. (2009). Gesundheitskonomische Begleitforschung (unpublished economic
evaluation report, German heroin-assisted treatment trial).
35
March et al. (2006), supra note 3.
36
Metrebian, N., Shanahan, W., Wells, B. & Stimson, G. (1998). Feasibility of prescribing
injectable heroin and methadone to opiate-dependent drug users: associated health gains and
harm reductions. MJA, 168(12), 596-600.
37
Killias, M. and Rabassa, J. (1997). Less Crime in the Cities Through Heroin Prescription?
Preliminary Results from the Evaluation of the Swiss Heroin Prescription Projects. The
Howard Journal, 36(4).
38
Lbmann, R. & Verthein, U. (2009). Explaining the Effectiveness of Heroin-assisted
Treatment on Crime Reductions. Law and Human Behavior, 33:1.
39
Perneger et al. (1998), supra note 3.
40
Dijkgraaf et al. (2005), supra note 28.
41
Lobmann & Verthein. (2009). Explaining the effectiveness of heroin-assisted treatment on
crime reductions. Law and Human Behavior, 33(1), 8395.
42
Id.
43
Haasen et al. (2007), supra note 3 at 55-62; P., Vincent, M. H., Maarten, W. J., Koeter, Van
Ree, J.M. & van den Brink, W. (2005). Matching of treatment-resistant heroin-dependent
patients to medical prescription of heroin or oral methadone treatment: Results from two
randomized controlled trials. Addiction, 100, 89-95; Franziska, G., Gschwend, P., Schulte, B.,
Rehm, J., & Uchtenhagen, A. (2003). Evaluating long-term effects of heroin-assisted
treatment: The results of a 6-year follow-up. European Addiction Research, 9, 73-79; March
et al. (2006), supra note 3 at 203-211; Oviedo-Joekes et al. 2009, supra note 3.
44
Ferri et al. (2005), supra note 4 at 10.
45
Strang et al. (2010), supra note 3.
46
Rehm et al. (2001), supra note 6.
47
Haasen et al. (2007), supra note 3.
48
Oviedo-Joekes et al. 2009, supra note 3.
49
Blanken, P., Hendriks, V.M., Koeter, M. et al. (2012). Craving and illicit heroin use among
patients in heroin-assisted treatment. Drug Alcohol Depend, 120, 1-3.
50
M., Hendriks, V.M., Van Ree, J.M., van den Brink, J. (2010). Outcome of long-term
heroin-assisted treatment offered to chronic, treatment-resistant heroin addicts in the
Netherlands. Addiction, 105(2), 300-308; Eiroa-Orosa, F.J., Haasen, C., Verthein, U. et al.
(2010). Benzodiazepine use among patients in heroin-assisted vs. methadone maintenance
treatment: Findings of the German randomized controlled trial. Drug Alcohol Depend, 112(3),
226-33; Haasen, C., Eiroa-Orosa, F.J., Verthein, U. et al. (2009). Effects of heroin-assisted
treatment on alcohol consumption: findings of the german randomized controlled trial.
Alcohol, 43(4), 259-64.
51
Perneger et al. (1998), supra note 3; Rehm et al. (2001), supra note 6.
52
Oviedo-Joekes et al. (2007), supra note 1 at 777.
53
Haasen et al. (2007), supra note 3.
54
Rehm et al. (2001), supra note 6.

55

Id.
Strang et al. (2012), supra note 2 at 48-50.
57
Haasen et al. (2007), supra note 3 at 55-62.
58
Rehm et al. (2001), supra note 6.
59
Vertein, U., Bonorden, K., Degkwitz, P., et al. (2008). Long-term effects of heroin-assisted
treatment in Germany. Addiction, 103, 960-966.
60
Lansier et al., supra note 29; Miller et al. (2010, 2011), supra note 29.
61
Lansier et al. (2010), supra note 29.
62
Miller et al. (2010, 2011), supra note 29.
63
Killias, M., Aebi, M.F., Jurist, K. (2000). The Impact of Heroin Prescription on Heroin
Markets in Switzerland. Crime Prevention Studies, 11.
64
Id.
65
National Institute on Drug Abuse. (2014). Drug Facts, available at
http://www.drugabuse.gov/publications/drugfacts/nationwide-trends.
66
National Institute of Drug Abuse. (2014). What is the scope of heroin use in the United
States?, available at http://www.drugabuse.gov/publications/research-reports/heroin/scopeheroin-use-in-united-states.
67
Id.
68
Office of National Drug Control Policy, Nevada Drug Control Update, available at
https://www.whitehouse.gov/sites/default/files/docs/state_profile_-_nevada.pdf.
69
Office of Public Health Informatics and Epidemiology and Office of Vital Records of the
Division of Public and Behavioral Health, Heroin and Opioid Related Mortality 2008-2012,
available at http://health.nv.gov/PUBLICATIONS/20082012_Heroin_and_Opioid_Related_Mortality_Fast_Facts_e_1.0_2014-03-06.pdf.
70
Chereb, S. (2014, April 5). Heroin use, deaths, on the rise in Nevada. Reno GazetteJournal, available at http://www.rgj.com/story/news/crime/2014/04/05/heroin-use-deathsrise-nevada/7350407/; Kitchen, R. (2014, February 6). Heroin use on the rise in Nevada.
Kolo8 News Now, available at http://www.kolotv.com/home/headlines/Heroin-Use-on-theRise-in-Nevada-243990401.html; Potter, J. (2012, October 2). Drug abuse turning deadlier in
Nevada. 2News, available at http://www.ktvn.com/story/19708773/drug-abuse-turningdeadlier-across-nevada.
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