Thursday, March 24, 2005

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

Wednesday, March 16, 2005

Harm Reduction: What's Not to Like?

FACT: a condition (call it medical, behavioral, hedonistic, self-inflicted, metabolic – whatever you like) exists that involves tens or hundreds of thousands or millions of people in their respective countries sticking dirty needles in their bodies several times a day, risking getting and spreading fatal illnesses (AIDS, hepatitis, among others), risking direct death from an overdose, and doing all this is a legal climate of zero tolerance that demands a variety of laws be broken in the process. All this at enormous expense in human suffering and in financial terms for the users, their families and for every person in the community at large.

FACT: nowhere in the world, despite the application of every conceivable form of prevention and treatment measure – including the most Draconian means of intimidation (long-term incarceration, hanging, beheading, torture) has proven effective in preventing or stopping this condition.

FACT: a variety of means have been demonstrated conclusively, in disparate countries of the world, under dramatically different social, political, economic and drug-using circumstances, to lessen the "harm" associated with this condition – to lessen it in a quantifiable manner by lowering spread of disease, risk of overdose, associated crime and death.

FACT: the various methods demonstrated repeatedly and consistently to reduce harm are remarkably easy to provide – no prohibitive production costs, technological sophistication, extensive training of particularly gifted workers, no elaborate training of the population at risk. Teaching safer-injection techniques and how to use a condom can be accomplished almost instantaneously with people who are illiterate and have never had a day of school attendance , - and with the intellectual elite who despite all their degrees are simply incapable of learning how to use a "Blackberry" – or even a DVD/VCR. I refer to provision and use of sterile needles and syringes, teaching mechanisms of transmission of diseases associated with drug use and/or commercial (or non-commercial) sexual activity, provision of effective treatment that is known to be acceptable to providers and recipients alike (most notably, "substitution treatment" with methadone and, more recently, buprenorphine), provision of treatment of concomitant illnesses such as tuberculosis, HIV-AIDS, hepatitis, etc. Perhaps most basically, I speak of the reduction in morbidity and mortality – i.e., the reduction of harm - that is possible with no more than a compassionate, respectful acknowledgement of the humanity of drug users.

FACT: not a single one of these varied interventions that we know reduce the harms associated with illicit drug use has itself been demonstrated to cause harm – except in truly exceptional instances that exist with every treatment of every medical condition (e.g., babies inadvertently take or are given excessive amount of aspirin and die; patients have allergic reactions to penicillin and die; people use (purposefully to seek a desired effect, or by accident) medications that are prescribed for others, with potentially serious – even fatal – outcome; physicians through inexperience or ignorance prescribe the wrong medication in the wrong dosage to the wrong person. And yet, these exceptional incidents notwithstanding, there is no logical reason for rejecting "harm reduction" measures on the basis of adverse, unintended consequences – some of which are enumerated above. Certainly, neither logic nor experience supports the fear of some that they will "encourage" non-users to use, that they will lessen the motivation of current users to seek assistance in quitting, that they will in some hitherto unknown way undermine the fundamental morality and inherent goodness that some attribute to all of God’s (as yet, non-drug-using) children.

SO WHAT’S THE PROBLEM? Why do people fight with such fervor to deny services known to save lives? Why are they so ideologically threatened that they (i.e., to be specific, the most powerful governments on the face of the earth) bully and blackmail their own citizens and those of other nations to forbid even the use of the words, "harm reduction"?
I am sure there are answers – there are always answers! I confess, however, with true humility, that I do not know what they are. Enlightenment will be welcome.

Tuesday, March 08, 2005

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)