Johns Hopkins University drug abuse experts and Baltimore's health commissioner are discussing the possibility of a research study in which heroin would be distributed to hard-core addicts in an effort to reduce crime, AIDS and other fallout from drug addiction.
The plan for a trial of "heroin maintenance" for some Baltimore addicts who have refused or failed in traditional drug treatment is still at a preliminary stage. Conscious that the issue could be politically explosive, the doctors involved are treading carefully and trying to persuade colleagues in other cities to launch such studies simultaneously.
In a sign of the growing willingness to consider controversial strategies against illegal drugs, experts on drug abuse from around the world met Saturday at the New York Academy of Medicine to discuss heroin maintenance. Public health specialists from a half-dozen cities in the United States and Canada then met Sunday at the Lindesmith Center, a drug policy institute supported by financier George Soros, to discuss the logistics and politics of a multi-city heroin maintenance study.
"It will be politically difficult, but I think it's going to happen," said Baltimore Health Commissioner Dr. Peter L. Beilenson. "It's not going out on the streets and handing out heroin. It would be carefully controlled by health care providers under a research protocol."
Beilenson, a physician who has an academic affiliation with the Hopkins School of Public Health, said he strongly supports a heroin maintenance study but believes it should be carried out by Hopkins researchers and not by Baltimore personnel.
"We would not use city money, and it would not be in city Health Department clinics," he said.
David Vlahov, a professor of epidemiology at the Hopkins School of Public Health who attended the weekend meetings, said the discussions are "pretty preliminary," but that data from a three-year study of heroin maintenance in Switzerland are encouraging.
Vlahov, who has tracked 3,000 Baltimore drug addicts for 11 years, said only 15 percent of intravenous drug users are in treatment and only 50 percent have ever been in treatment. Offering controlled doses of heroin might lure some addicts off the street and into a setting where they can get health care and counseling and eventually kick the habit, he said.
"Heroin maintenance is an outreach strategy to bring people into the system," Vlahov said.
Other Hopkins researchers who have discussed a possible heroin maintenance trial are Dr. George E. Bigelow, who runs the Behavioral Pharmacology Research Unit, and Dr. Robert K. Brooner, director of addiction treatment services at Hopkins' Bayview campus. Both expressed interest in the proposal but said Hopkins has not made any decision about participating.
Brooner noted that heroin maintenance is "not revolutionary," since doctors routinely give methadone and other substitute drugs to addicts in treatment. Methadone can be given in once-a-day oral doses, while heroin would probably have to given by injection three times a day, he said.
"My guess is we could reach some patients who are not being reached," said Bigelow, who has studied drug abuse at Hopkins for 27 years.
In addition to Baltimore, the researchers who met Sunday came from Chicago, New Haven, Conn., San Antonio and Sacramento, Calif., as well as the Canadian cities of Toronto, Montreal and Vancouver. Participants said details of funding, scientific research design and numbers of participants have yet to be worked out.
Heroin maintenance trials would require approval from the Food and Drug Administration and probably from the Drug Enforcement Administration as well, researchers said.
The debate brewing over heroin maintenance echoes the 10-year-old controversy over the distribution of clean needles to drug addicts to reduce the spread of acquired immune deficiency syndrome.
Needle exchange programs have faced bitter political opposition and President Clinton decided not to provide federal funding this year for such programs, despite a finding by Health and Human Services officials that they curtail transmission of the human immunodeficiency virus that causes AIDS.
On one side of the drug debate are those who, like Beilenson and Mayor Kurt L. Schmoke, consider the U.S. war on drugs to be a costly disaster that has filled the prisons without reducing the devastation inflicted by narcotics. These drug policy reformers advocate treating drugs chiefly as a health problem, not a law enforcement problem. They have embraced a philosophy of "harm reduction," which seeks strategies to reduce the death, disease and crime resulting from drug abuse.
Such advocates have received funding in recent years from Soros and philosophical encouragement from Ethan A. Nadelmann, the lawyer and drug policy expert who heads the Lindesmith Center.
On the other side are those, including political conservatives but also many drug abuse experts, who believe that prosecution of drug users does discourage drug use.