Back in the 1990s, Switzerland pioneered heroin-assisted treatment—successfully addressing HIV and overdose crises by offering an early form of safe supply, along with other social and medical supports.
In the years since, there have been further developments in the intervention. In 2008, for instance, some of the country’s clinics began making oral tablets of pharmaceutical-grade heroin (diacetylmorphine) available for participants who either wanted to discontinue injecting or who weren’t injecting in the first place.
However, these options don’t always meet every participant’s needs, according to Marc Vogel, head of Addiction Medicine at the University of Basel Psychiatric Clinics, which has a heroin-assisted treatment outpatient program. While some people may want to avoid injecting, they may still desire the “rush” or rapid onset that injecting provides—but which is missing if you use the tablets.
Vogel and colleagues across Switzerland developed a new way of providing heroin-assisted treatment: a nasal spray.
“You don’t have the same feeling—no rush, [the high is not] the same high as you get from injecting,” Dr. Vogel told Filter. And some people who don’t want to inject nonetheless “need this high in order to stabilize.”
To meet this need, Vogel and colleagues across Switzerland developed a new way of providing heroin-assisted treatment (HAT): a nasal spray.
Vogel, along with his colleagues and their associated out-patient clinics, recently released a paper, published in the Harm Reduction Journal, showing the results of a four-week observational study in which interested HAT participants were able to access the spray.
The team had first considered different options for a new route of administration for HAT. An early idea was taking the available heroin tablets and crushing them so participants could snort them—which many people were doing anyway, Vogel noted. However, there are various other compounds that go into the pills, he said, such as silicates, which could get into and damage the lungs if snorted. “From the point of harm reduction, this is not optimal.”
The team then turned its attention to the injectable formulation of heroin used in Swiss HAT. And in 2018, they tried adding atomizers to the syringes. The atomizers they used simply screw on the top of the syringe. You just need to push the plunger, then the liquid is forced through the atomizer into a fine mist that you can inhale through the nose.
The atomizers are totally mechanical, rather than electric, Vogel said. They are similar to those used to turn naloxone into a nasal spray to reverse opioid overdoses.
Some of the clinics involved started providing this option to a few people between 2018 and 2019 and saw that it worked quite well for some of them. From there, they worked with other treatment centers around Switzerland to do the observational study described in the paper, which the centers began in late 2020.
In all, around 20 centers agreed to be involved in the study. Across these facilities, 52 participants agreed to take part. The research team provided them with the spray and observed how it changed their heroin consumption over four weeks.
One of the main reasons the team heard for wanting to try the spray was that long periods of injecting had damaged some people’s veins. Another reason was that many of the participants simply preferred snorting heroin over other methods. Yet another was that the oral tablets did not have a strong enough effect. Others wanted to switch away from, or reduce, their injecting in favor of a potentially less risky consumption option.
After the four weeks, 47 respondents, or a little over 90 percent, were still using the nasal spray. Further, the weekly average of injections among participants decreased by 44 percent compared to the month prior. The paper also noted that no “severe adverse interactions were reported.”
“We think it’s a useful tool. It’s just one tool in the toolbox, right?”
“We think that for a subgroup of patients, this is a very attractive means of opioid agonist treatment,” Vogel said.
He added that in theory, this route of administration could expand to include other opioids, such as fentanyl. To his knowledge, fentanyl-assisted treatment programs like Swiss HAT do not exist—though he and other researchers have proposed it as an option. Fentanyl is not found in the Swiss heroin supply to anything like the extent of North America, so Vogel said that it wouldn’t realistically be possible for his team to study a nasal fentanyl spray. But he noted how some people in North America seek fentanyl and its analogs—and fentanyl safe supply programs do exist in Canada—so a spray formulation could be an option to consider there.
Vogel also cautioned that the results from the new study are just “preliminary,” meaning there’s room to learn more about how the spray impacts people accessing HAT. The clinics involved are currently recruiting more interested participants to gather more data, he said.
But in all, the nasal spray appears to be a success at this moment. To remove barriers to accessing programs like HAT, Vogel said, practitioners need to take steps that include offering a variety of routes of administration, so people can find what works for them. “We think it’s a useful tool. It’s just one tool in the toolbox, right?”
Photograph via FreeImagesLive.co.uk/Creative Commons 3.0
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