How much longer will America withhold effective treatment from those who want it, need it, and whose lives might be saved with it?

This posting addresses the just-published paper on “Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users.” 1 The authors have provided a valuable, comprehensive summary of the evidence supporting the enormous potential of opiate agonist treatment, and the extent to which this potential is and is not being fulfilled in various regions of the world. In countries that remain resistant to permitting any opiate agonist treatment (e.g., Russian Federation, Ukraine and others), “cautious introduction” may be unavoidable, but it is painful to contemplate the suffering and loss of life that “caution” brings with it.

Here in the US, however, there seems to be no excuse for failure to move forward on a massive scale for all who are willing. We have 40 years experience with methadone, and two+ years with buprenorphine.” And yet, virtually nothing is happening! Four years ago “only 170,000 of the estimated 810,000 opioid-dependent individuals in the US” were able to receive “the most effective medical treatment for opioid dependence – opioid agonist maintenance.”2 And today? Maybe – at best- a few thousand more, though data with respect to incremental patients appear to be unavailable, suggesting no one cares enough to even count!

How much longer will America withhold effective treatment from those who want it, need it, and whose lives might be saved with it? How much longer – and with what associated costs in dollars and illness and lives – will America ignore the proven ability to expand access to opioid agonist therapies for drug users? While pondering these questions – and their staggering implications – we might consider the audacity of America’s “Drug Czar,” John Walters, who reportedly has been on the stump in Europe, extolling our “balanced strategy” on drugs, and damning the efforts of other countries to lessen morbidity and mortality – i.e., to promote harm reduction. Until the U.S. gives some hint that we take seriously the lives and welfare of our own citizens, our government leaders should maintain silence on the international front when it comes to dealing with the drug problem.

1.Sullivan LE, et al. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction 100:150-158, 2005

2.Fiellen DA et al. Methadone Maintenance in Primary Care: A Randomized Controlled Trial. JAMA 286(14):1724-1731, 2001

3.Watson R. US official preaches benefits of “drug courts” in curbing misuse. BMJ 330:560

Where are the advocates for drug users?

There are advocaters for those suffering from virtually every medical condition - from the most common to the ultra-rare. In many instances advocacy groups have played indispensable roles in lessening discriminaiton and enhancing and expanding treatment access. "Mental illness," HIV-AIDS, epilsepsy etc etc. Generally the most effective advocates are not the patients themselves, but their families and loved ones (gays andLesbians marching down Fifth Avenue chanting "we're queer, we're here, get used to us!" was terrific; probably even more persuasive for middle America were the legions of gray-haired senior citizens chanting their kids were gay and damn well deserved every single right and privilege of any other American).

In Europe as well: "junky unions" in Holland did a great job demanding their rights. But in Germany, it was - and remains - up to parents groups, located in cities and villages throughout the country, exerting incessant pressure of public officials and the media - vehemently damning the suffering and death caused by unjust and irrational drug policies.

So . . . where are the advocates for illicit drug users in US - and to narrow the discussion just a bit, the advocates for the most despised, feared, abandoned of all, the intravenous narcotic users? Why are there no parents marching down Fifth Avenue - or any Main Street, USA - demanding treatment, measures known to reduce harm and preserve lives, an end to the persecution that is inherent in a "zero-tolerance" policy, a willingness by Government to teach users to lessen their own risks and lessen incidental harm caused to others, etc.? Why are there large, active, highly effective parents and other support groups in Europe, and Australia, and other countries - but nothing in US? And whatever the cause(s), how to overcome the hurdles?

rnewman (NYC)