Pubdate: Sat, 29 Apr 2006 Source: Vancouver Sun (CN BC) Copyright: 2006 The Vancouver Sun Contact: http://www.canada.com/vancouver/vancouversun/ Details: http://www.mapinc.org/media/477 Author: Peter McKnight, Vancouver Sun Bookmark: http://www.mapinc.org/find?136 (Methadone) Bookmark: http://www.mapinc.org/rehab.htm (Treatment) GIVE THE ADDICTS THEIR DRUGS For those who bicker over two of the four pillars, harm reduction and treatment -- Mayor Sam and Senator Larry, please take note --heroin maintenance happens to be both To hear former Vancouver mayor Larry Campbell tell it, current Mayor Sam Sullivan's proposal to provide drugs to addicts is "very simplistic." Yet in dismissing Sullivan's proposal, Campbell, who clearly prefers the bully pulpit of the mayor's office to the sober second thinking of the Senate, revealed that when it comes to drug addiction, there's enough simplistic thinking to go around. After all, Campbell also supports giving drugs to addicts, but only to those who have failed to respond to other programs. So he argues that Sullivan's proposal -- which might involve providing drugs to a broader array of addicts -- amounts to emphasizing harm reduction at the expense of treatment. The former mayor's argument therefore reveals that he believes harm reduction and treatment are necessarily two different things, and never the twain shall meet. And Sullivan seems to agree, since he opined that treatment doesn't need to be a priority right now. Thus, despite their minor disagreement -- which merely concerns how far gone addicts have to be before being eligible for free drugs -- the current and former mayor aren't so far apart after all, in that they both agree that harm reduction and treatment are two separate modalities, that harm reduction involves giving addicts what they want, while treatment involves refusing to do so, as it begins and ends with abstinence. Now, that's simplistic thinking. Contrary to what the mayors seem to believe, it's not always possible to distinguish harm reduction from treatment. Indeed, while prescribing heroin to addicts is usually viewed as harm reduction, heroin maintenance is really a form of treatment, a means of stabilizing addicts physically, emotionally and economically. And it's a treatment that has been around for a long time. Even the United States, which now characterizes all illicit drugs as The Great Satan, operated narcotic maintenance programs until 1925, when drug hysteria, motivated by anti-Chinese sentiments, precipitated the end of such programs. (Anti-Chinese racism also led to the passage of Canada's opium laws in the early 20th century.) The United Kingdom also ran opiate maintenance programs in the 1920s, and continued the practice until the early 1970s, when U.S. opposition led to severe curtailment of the practice. According to the Drug Policy Alliance, closure of the programs resulted in a dramatic increase in heroin users in the U.K. -- from 2,000 in 1970 to more than 300,000 by the early 21st century. Concerned about this development, British police associations advocated expanding heroin maintenance programs, and the U.K. has recently done so. Of course, there were likely other factors that contributed to the increase, but the skyrocketing number of users suggests that heroin maintenance programs might qualify not just as harm reduction and treatment, but as preventive measures as well. All of which means they satisfy three pillars of Vancouver's four pillar strategy -- prevention, enforcement, harm reduction and treatment. Buoyed by the U.K. experience, other European countries began experimenting with heroin maintenance. Between 1994 and 1997, the Swiss government provided heroin to 1,000 long-term addicts who had failed at more traditional forms of treatment. According to a report from the North American Opiate Medication Initiative (NAOMI), 69 per cent of subjects remained with the Swiss program for its 18-month duration, and more than half of the dropouts became abstinent or switched to other treatments. And the dropout rate was significantly lower than the rate seen in studies of methadone maintenance. Further, the Swiss subjects experienced improvements in almost every aspect of their lives. Participants reported a dramatic decrease in drug use, and while 43 per cent of subjects lived in unstable housing at the start of the study, 18 months later that number was reduced to 21 per cent. The rate of employment more than doubled, to 32 per cent from 14 per cent, and arrest rates declined from 69 per cent to 10 per cent. Indeed, Swiss police registered a whopping 50-per-cent decline in all offences, which led the Swiss public to vote in favour of a long-term heroin maintenance program. There was one significant drawback of the study, however. Researchers did not include a control group -- that is, they didn't provide some addicts with methadone or other forms of treatment to compare to the heroin maintenance group. We therefore can't assume that the results obtained were solely attributable to the provision of heroin. Aware of this limitation, Dutch researchers began a study in 1998 that compared the effects of methadone maintenance with a treatment involving a combination of heroin and methadone. The results were similar to those obtained in the Swiss study -- participants receiving heroin enjoyed vastly improved physical, mental and emotional health, improved social functioning, and experienced a reduction in criminal behaviour. Most importantly, the benefits of heroin/methadone treatment were significantly better than the benefits of methadone-only treatment. There was also one drawback to this study, though it wasn't a result of the study's design: Researchers found that more than 80 per cent of those receiving heroin deteriorated substantially following discontinuation of the heroin treatment. (One further limitation of all heroin studies is that their results can't be generalized to the provision of other drugs, such as cocaine or methamphetamine, given their different psychopharmacological properties.) In any case, that heroin maintenance produced, among other things, better physical and mental health reveals that it can't be characterized as a mere harm reduction measure but is, in fact, a form of treatment, and a powerful one at that. Certainly, heroin didn't "cure" the subjects, in that they continued using drugs, but then again, many treatments don't cure diseases. It is this misguided, utopian belief in a cure -- that treatment is only treatment when it leads to abstinence -- which constitutes truly simplistic thinking, and which leads us to dismiss potentially efficacious therapies. The sad fact is, some addicts won't stop using drugs for a long time, and some might never stop. But that's no reason to refuse to treat them, to refuse to do what we can to improve their -- and our -- quality of life. After all, while some people understandably object to giving addicts what they want, to paying for their habit, we're already paying for it. Heroin addicts account for enormously increased health care costs, prison costs and costs associated with home and car break-ins. According to NAOMI, the societal costs of untreated heroin use amount to $45,000 per addict per year, and with between 60,000 and 90,000 opiate addicts in Canada, the total annual tab is $2.7-$4 billion. For all of these reasons, the NAOMI trials are underway in Vancouver and Montreal, and will compare the efficacy of prescribing heroin/methadone with methadone-only treatment. While we can't be certain that the results of the Swiss and Dutch studies will be replicated here, preliminary results suggest that heroin treatment is having a positive effect. If these results are confirmed, then it will be time for the current and former mayors to quit their bickering over which pillars are most important. Indeed, it will be time for anyone who values either harm reduction or treatment to support heroin maintenance, because it happens to be both. - --- MAP posted-by: Derek