Pubdate: Wed, 21 Oct 2009 Source: National Post (Canada) Copyright: 2009 Canwest Publishing Inc. Contact: http://drugsense.org/url/O3vnWIvC Website: http://www.nationalpost.com/ Details: http://www.mapinc.org/media/286 Bookmark: http://www.mapinc.org/hr.htm (Harm Reduction) JUMPING TO CRACK CONCLUSIONS One of the caveats against a harm reduction approach to drug abuse is that you have to be pretty sure the steps you are taking will actually reduce harm. Researchers in Vancouver have taken an audacious step this week by calling for crack cocaine use to be considered an independent source of HIV risk, based on a new local study in the Canadian Medical Association Journal, and recommending the possible adoption of "safer crack kits" and supervised inhalation rooms at existing drug-injection sites as strategies for reducing the spread of the virus. This will not, it should go without saying, make the debate over Vancouver's existing harm-reduction infrastructure any less complicated than it already is. The federal government is fighting in court for the ability to shut down the city's Insite program; now, at the same moment, many of Insite's traditional defenders are effectively suggesting that the program ought to be expanded, in order to deal with an increasingly prevalent crack problem that is more dangerous to public health than previously thought. The CMAJ study was a retrospective re-analysis of the nonrandom sample of participants in the longitudinal Vancouver Injection Drug Users Study (VIDUS) which began in May 1996. All the participants are people who had used some illicit injectable drug less than one month before entering the study; the researchers broke out the 1,048 who were HIV-negative when enrolled, and compared the daily crack users going forward with the other drug users. What they found was that, after controlling for other possible confounding variables, the daily crack smokers appeared to be 2.7 times as likely to acquire HIV over the next nine-and-a-half years as the other junkies. The harm reductionists will, as is their habit, declare that this means the evidence is in and that human decency demands the policy interventions they propose. We are prepared to agree with the core logic of their position: If the evidence truly supports a harmreduction approach to crack, we should not let squeamishness or superstition, or some idea that crack has subtle moral differences from heroin and other injectable drugs, keep us from trying it. We would like it if they would recognize that any harm-reduction step always carries attendant dangers of encouraging or facilitating abuse, however insubstantial, and that the tricky calculus of giving crack users free crack pipes and a place to use them may have subtle differences from that underlying Insite's established work. The real problem is that their evidence, while raising a scary possibility that needs to be investigated more closely -- namely, that crack use is an independent risk factor for HIV on the same order as drug injection -- is not yet a slam dunk. They leap from their statistical findings to the suggestion that crack may facilitate HIV seroconversion because crack pipes "produce wounds in and around the mouth" which would create an infection route during subsequent pipe-sharing or oral sex. But the caveats are abundant. As the researchers acknowledge, they didn't test for this precise hypothesis directly; VIDUS participants weren't checked for oral health. There exists the obvious possibility that crack users may be more prone to HIV primarily because they have more sexual partners and more unprotected sex of other kinds. The only sexual-behaviour variables the VIDUS data allowed the authors of the study to control for were participation in sex work and unprotected sex -- as in, "Have you had unprotected sex at least once in your entire life?" An editorial commentary attached to the paper in CMAJ rightly describes this as a "crude simplification" that "may have eliminated a possible significant association." It notes the further logical problem that "oral sex has not been shown to be significantly associated with HIV transmission" in any way. And the statistical power of their subset of VIDUS participants was not great. (The 95%-confidence limits on either side of that figure of 2.7 reach all the way from 1.06 to 7.1, so there is still a fairly significant chance that crack use alone has only a slight effect on HIV vulnerability.) The "sex-for-crack" lifestyle is already known to be one that increases HIV/AIDS risk; the Vancouver researchers have really told us nothing that is not already consistent with that fact of life. The question is how much of that additional risk is the result of their oral-health hypothesis. If the answer is "not very much," then harm-reduction measures specifically intended to protect the oral health of crack users won't accomplish much. We would need to consider an intervention that stops crack addicts from having sex with many strangers to obtain crack or money for crack. To which one is tempted to add a cynical "good luck." - --- MAP posted-by: Jo-D