May 9, 2000
Dr. Charles O'Brien
I want to thank Mr. Chairman, Senator Grassley and Senator Biden for inviting me today to testify. And I also want to applaud the young people who are here today to talk to us in such a personal way about the negative impact heroin has had on their lives.
We are here today to discuss the growing heroin addiction problem that is resulting from high purity levels. We also need to recognize that heroin addiction is a chronic relapsing brain disease for many people. To address this growing problem, we need to increase treatment options and allow qualified physicians to diagnose and treat opiate addiction in an office-based setting.
As background, our clinical program at the Philadelphia Veterans Affairs Medical Center treats about 10,000 veterans each year with mental disorders. About a fourth of these patients have primary substance use disorders, and another third have combined substance abuse with other mental disorders. The treatment program, one of the largest and oldest in the VA has received the Award of Excellence from VA Headquarters and is a National Center of Excellence for Substance Abuse Training. We are also the site of a VA Mental Illness Research, Education and Clinical Center (MIRECC) with a substance abuse theme. and a NIDA Research Center that includes a network of 15 non-VA programs throughout the Delaware Valley. We teach medical students, residents and fellows and we host a national training program for minority medical students in treatment of substance use disorders.
In studies dating back to the early 1970s, our group has been credited with the development of several new treatments for addiction, new understanding of the brain mechanisms underlying addiction and for inventing the standard measuring instrument for measuring the severity of addiction used throughout the world. Our research deals with the four main addicting drugs: nicotine, alcohol, heroin and cocaine. While addiction to the two legal drugs, nicotine and alcohol, is responsible for many more deaths and economic loss than heroin and cocaine, my remarks today will emphasize the current facts concerning the new problems caused by the unprecedented availability of very potent heroin.
Before beginning to speak about heroin, I must mention that there is good news to report regarding cocaine abuse. New cases of cocaine abuse and dependence have fallen off dramatically, particularly in New York City. Crack cocaine dealers have been quoted as saying that they can no longer make a living selling this drug. Cocaine in both crack and powdered forms is still widely available and cheap in our area, but fewer people seem to be buying it. This development is not surprising since previous stimulant epidemics have been self-terminated in the past, both in this country and abroad. We would like to give credit to drug prevention programs, but there are also other important factors. We believe that decline of new users is related to the fact that cocaine produces destruction of lives fairly quickly and thus prospective new users can see the deterioration in their older friends and relatives and decide not to begin using the drug themselves. Heroin, in contrast, is less toxic. It simply mimics the effects of normal hormones that all of us have and produces social destruction more gradually. Although heroin can cause death by overdose, the medical consequences of heroin use are mainly indirect based on infections such as AIDS and hepatitis.
While there is good news to report about the availability of new and effective treatments for heroin addiction, there is also much grim news to report. Heroin purity is up all over the country and my home town of Philadelphia has the sad distinction of having the most potent heroin in the country according to DEA figures over the past several years. When we founded our treatment program in 1971 and continuing until the 1990s, the average purity of a bag of heroin was 4 %. Lately it has increased to as much as 85% with most bags tested falling into the 70% range. In other parts of the East, the figures are only slightly lower. Thus heroin per milligram is cheaper than ever in modern history. This increased purity is reflected in overdoses and in high levels of physical dependence observed in patients who come to us seeking treatment. Moreover, we are seeing increasing numbers of young people starting on heroin as smokers or "snorters," that is, taking heroin by placing the powder in their nostrils. Heroin today is so potent that they are able to get effects by smoking it or absorbing it through the membranes of their noses rather than being obliged to inject it. This is exactly what I heard from my military patients as a US navy physician during the Vietnam War. Our current heroin purity and use patterns are similar to the tragic situation in Vietnam. Unfortunately, studies show that at least 15% of the "snorters" and smokers progress to injection in the first year. More middle class and suburban youths are being introduced to heroin. We have been studying the Philadelphia needle exchange program, which incidentally has shown efficacy in reducing the spread of infections, and we were shocked to find on the first day of the study a group of students from our own university who were coming to get needles for their heroin injections.
While our first goal in the treatment of heroin addiction is complete abstinence, we know that this is not realistic for the great majority of patients. Even those who do well initially in a drug free residential program have a high frequency of relapse when they return to the neighborhood where drugs are available. Methadone treatment, invented in the 1960s, has a proven record of success for the majority of heroin addicts. It is unfortunate that some politicians are calling for a reduction in methadone therapy, while most metropolitan areas have long waiting lists for methadone treatment, and less than 200,000 of an estimated 800,000 addicts are receiving treatment. In spite of the increased purity of heroin on our streets, treatment resources are inadequate and options are limited. They should be expanded, not reduced. Methadone is not even available in eight states. Fortunately, we have a very effective spokesperson in General Barry McCaffery who has eloquently made the case for more methadone availability and for additional treatment options for heroin addicts.
Methadone has saved the lives of many heroin addicts, but because of public misunderstandings, it has a controversial reputation. Several years ago in response to an invitation from Congressman Porter to speak on the progress in addiction research, I brought with me a young women who has been maintained on methadone for many years. She is now a practicing attorney and a mother, but she continues to require methadone. Her testimony to the committee discussing the NIH budget was eloquent and she responded to questions beautifully. Most of the committee members were incredulous that she was really on methadone because she looked so "normal."
In addition to methadone, we have other treatment options for the treatment of heroin addiction. LAAM is a medication approved by the FDA about five years ago, but it is little used in treatment. LAAM is an excellent medication that for some people is even better than methadone and its duration of action is so long that it need be taken only two or three times per week. It should be much more widely available and it is a weakness of our overly restrictive treatment system that more patients do not have the opportunity to receive this medication.
Another new medication that is being successfully used in France and is currently being reviewed by the FDA for use in the U.S. is buprenorphine. Its chemical category is somewhat different from methadone in that it is a partial agonist at opiate receptors. This medication has been found to be as effective as methadone and in some cases even better. It seems to be particularly effective for adolescents with a heroin problem. Buprenorphine is very unlikely to produce overdose and in France, the death rate due to opiate overdose has dropped by about 75%. Not only does it not produce overdose itself, but it may even provide a measure of protection against overdose by heroin.
The safety and efficacy of buprenorphine is such that it should be made available to all physicians to treat patients with opiate problems in their offices. This would be a major benefit to patients who are unable or unwilling to come to specialized methadone programs. It would be available not just to heroin addicts, but to anyone with an opiate problem, including many citizens who would not ordinarily be associated with the term addiction. The availability of buprenorphine would enable physicians to control the opiate abuse problems of many Americans who are now being inadequately treated or not treated at all.
One important development is the combination of buprenorphine with naloxone, a full antagonist. If the combination is taken by mouth, this new medication is effective in reducing drug craving and stabilizing the person to lead a normal life. If someone tries to abuse it by injecting it, the naloxone component would then be effective in blocking the effects and preventing a "high" or euphoria. Thus, the diversion potential of this new medication should be minimized.
Several treatment programs have already studied buprenorphine in the treatment of adolescent heroin abusers. It has been found to detoxify, that is treat withdrawal symptoms, while the body cleanses itself of heroin, more effectively than other medications. Thus a greater proportion of young people are able to get off of heroin and receive counseling and other forms of rehabilitation. Buprenorphine is also very effective as a longer term medication that a young person can take daily, return to school or job training and after six months or more maintain a stable drug free state. Once this medication is approved by the FDA and is allowed to be used in physicians' offices, it could dramatically improve the treatment of heroin addiction in the U.S.
The current heroin treatment situation is ironic. Through research we have developed more effective treatments than ever before. We have the medicines I just described. We have strong evidence for the efficacy of counseling and psychotherapy in combination with medications that can produce impressive rehabilitation of heroin users. But we have an inadequate number of treatment slots and inadequate funding of the slots that do exist. Medication alone has only minimal benefits compared to the much greater effects of counseling and psychotherapy for patients in methadone or other medical treatments.
In summary Mr. Chairman, we are in the midst of the highest availability of relatively pure heroin in our recorded history. Fortunately we have effective treatments including new medications that are coming on line. One of them, buprenorphine, is well advanced in the FDA approval process and is being considered for use in a new approach to opiate addiction. This new approach, in keeping with the scientific data, would allow physicians to treat heroin addiction in their offices just as we treat any other medical problem.
Mr. Chairman thank you again for inviting me to testify here today. The issue of teen heroin abuse is a national problem. I hope my testimony will help you and your colleagues to move forward to implement the next phase of our nation's war on drugs ensuring that all of our heroin addicts have access to these effective treatment options.