Thursday, December 27, 2007


Two specific words that have been criticized are "blockade" and "substitution." Here are some thoughts - and comments are welcomed as always.

Over the years many have made the same observation that "blockade" is an unfortunate term (so is "antinarcotic agent" which dole and nyswander also used in a paper presented in London in 1967 and reprinted in Br J Adict, 1968, vol. 63, pp55-57. Blockade is not an action of methadone; it is an unscientific (and probably misleading) term that simply refers to tolerance, a phenomenon that any 1st or 2nd year med student understands and virtually all physicians have experienced to their frustration and their patients' pain.

As for "substitution" - D and N criticize in the paper cited the term in a very specific sense: " needs to be well understood that methadone can be used as an antinarcotic agent, blocking the euphorigenic action of narcotic drugs rather than substituting for them." So certainly, they condemned the notion that methadone treatment provided a substitute high I doubt, though, that D or N would have cared in the least (they almost certainly would have applauded) advocates who shouted from the rooftops that methadone maintenance substituted a legal medication that enhances and prolongs life for an illegal substance that is associated with horrendous costs of suffering, sickness and death (as well as terrible consequences for the community).

I know it's presumptuous of me, but based on my long-standing and close relationship with D and N I am convinced they would focus on practical issues: they'd be thrilled that in Germany and Switzerland, for example, care is available to all who need it, from community-based generalists as well as "programs," with relatively modest constraints - even though in those countries the term "substitution" is almost universally used. By the same token, i'm convinced their horror over the therapeutic tyranny practiced in so very many USA "programs," and the severe limitations on access to humane and respectful community-based treatment, would not have been mitigated in the slightest by virtue of the strong and indignant campaign to get rid of the term "substitution."

Sure, in the best of all worlds where we had no major concerns except semantics, we could all push for the most correct and precise terminology. But in USA, with virtually no one seemingly giving much of a damn about the fate of the estimated 80% of heroin dependent folks having no access to care, I feel a semantic preoccupation is a diversion. And the other 20% who do receive methadone treatment have far far more serious problems - problems associated with the exercise of power by "program" staff who all too often demand they accept "contracts," make medication a function of meeting "contingencies," videotape their urination and terminate patients whose urines are "dirty" - etc. Don't mean to generalize - but God knows these are not issues to trivialize either. And I do respectfully suggest they should be far, far higher on the list of priorities to criticize than semantics.


And so it is with the following bottom line of a position statement of the Italian Society of Addiction Medicine (Heroin Addiction and Related Clinical Problems, 9(2):June 2007, 5-10): "Effective treatment is far from being actually available to all those who apply for it, let alone those who may benefit from it. The first step . . . [must be] to spread and enhance resources to grant patients with correct and powerful application of effective techniques, methadone/buprenorphine maintenance being regarded as the gold and first-line standard for the average addict. If that will ever be the case, as we hope, we would need to provide patients identified as refractory with a salvage option, along the concept of harm reduction. In any other context, the intrduction of heroin administration programs would rather reduce the benefit than the harm." We welcome comments.

Tuesday, December 18, 2007


A recent article discusses "addiction recovery: its definition and conceptual boundaries" (J Subst Ab Treatm 2007; 33:229-241). Among the various perspectives cited is that of ASAM, which defines recovery as a "process of overcoming both physical and psychological dependence on a psychoactive drug with a commitment to abstinence-based sobriety". Also cited is Narcotics Anonymous World Services, whose Board of Trustees "affirms the right of NA meetings to refuse to allow those using medically prescribed methadone as 'drug replacement therapy' to speak at meetings and refers to such individuals as 'under the influence of a drug,' 'still using,' and 'not clean.'" The reference for the ASAM position is 1998, and that of NA's Board is 1996. However, we're unaware of any publicized change of position of either.

Clearly, we have a long way to way to go - still! - before narcotic addiction is recognized as a chronic medical problem for which medication can be not only appropriate but life-saving. The challenge of gaining acceptance for this view, put forth originally 42 years ago by Dole and Nyswander, is greatest among our colleagues in the field of addiction treatment.

Thursday, December 13, 2007


Drug Policy Gumbo
Report from the International Drug Policy Reform Conference, New Orleans.
Gumbo is a soup or stew originating in Lousiana. It’s a special mixture of vegetables, meat and spices, it can be made in different styles (e.g. Creol and Cajun), it is a byproduct of the meeting of various European, African and American cultural traditions. Gumbo is one of the symbols of New Orleans, the capital of Louisiana, which is located at the crossroads of geographic regions and civilizations, a town which synergizes religions and cultures. The Big Easy – as Americans call it – hosted the 20th biannual conference of the Drug Policy Alliance, the leading drug policy reform organization of the United States. As a local organizer pointed out, the conference itself aimed to create a big drug policy gumbo: gathering people from various parts of the world, with various backgrounds, ideologies, faiths, prejudices and interests. Liberals, conservatives and libertarians, black and white, researchers and activists, pot smokers and heroine injectors, elderly and young, law enforcement officials and hippies, sex workers and clergymen. There is only one thing which makes these folks allies, claims Ethan Nadelmann, Executive Director of the DPA: they all want to put an end to the futile war on drugs, which costs so many lives and tax payer dollars every year. And this eclectic movement is growing rapidly: this year we could witness an unprecedented number of participants and a very broad agenda which satisfied the interests of harm reduction pragmatists and marijuana enthusiasts as well.

This year the conference was co-organized by many other US drug reform organizations, such as the Harm Reduction Coalition (HRC), the American Civil Liberties Union (ACLU), the Students for Sensible Drug Policy (SSDP) and the Law Enforcement Against Prohibition (LEAP). The International Network of Drug Users (INPUD) also organized a side event with many participants from the North-American user movement. There were more than 50 breakout sessions, covering various issues from overdose prevention to entheogens science. There was a workshop on harm reduction therapy, which attracted many professionals and activists. Participants could also enjoy thought-provoking movies on the harmful consequences of the war on drugs at the film festival. A European Roundtable Discussion presented the major trends in drug policy in Europe, where Sofie Pinkham (OSI-IHRD) introduces to the audience the situation in Russia and Ukraine, while Peter Sarosi (HCLU) spoke about advocacy campaigns in Hungary. There was a very interesting session on heroin prescription, where we were updated about the latest results of heroin trials in the Netherlands and Canada. Promising news came from Denmark, where the government committed itself to introduce heroin prescription for hundreds of addicts in 2008. At the session on race and drug war we could learn how devastating impacts the war on drugs has on Afro-American communities, and how difficult is to mobilize community leaders to speak up against it because of the double stigma. Participants could also go for a guided tour to the flooded areas of New Orleans, where the destruction of the Hurricane Katrina is still visible: many people are still homeless and live in poverty because of the neglect of government. Most of them are Afro-Americans, who also suffer from racial profiling and ill-proportioned imprisonment rates as a direct consequence of the war on drugs.

One of the most interesting panels of the conference was a public debate between Antonio-Maria Costa, the head of the United Nations Office on Drugs and Crime (UNODC), the czar of the global drug control regime and Kasia-Malinowska Sempruch, director of the International Harm Reduction Development Program of the Open Society Institute (OSI). The audience appreciated the curage of Dr. Costa to face a huge crowd of people hostile to the very principles of his work. He acknowledged that the drug free world – a slogan of the General Assembly of the UN in 1998 – is not a realistic goal. He claimed that neither he nor any official UN documents have ever used this term. He introduced a new magic word: containment. Comparing to the harms done by licit drugs like tobacco or alcohol, the harms and abuse of illicit drugs remained low and isolated, Costa said, and this is due to the efforts of the global drug control system, which contained the illicit drug problem in a managable level. As an economist he agreed with the argument of the legalizers that prohibition creates a lucrative black market for criminals which creates violence and public health harms. However, he said, drug problem is not solely an economic issue, and the state has a duty to protect the society from the harms of drugs. He called the audience to „be more radical” and go beyond harm reduction as simply providing needles and substitution. The participants expressed their disagrement during his speech, but the atmosphere was not hostile, rather cheerful. Responding to Costa’s speech, Kasia-Malinowska Sempruch pointed out in her presentation that there is a direct, causal relation between repressive law enforcement policies – based on the UN drug conventions and supported by UNODC’s funding – and deteriorating public health conditions, especially the global HIV/AIDS pandemic. The simple medicalization of the problem is misleading, because many governments apply coercive, ineffective measures as „treatment”, especially in Asia, where labour camps are often masked as treatment centers. In the former Soviet countries most drug users have access to low quality inpatient treatment in closed hospital wards only, where their human rights are systematically violated. Even if there is a massive increase in substitution treatment in China, the centers are under close police control and they are not attractive for drug users, therefore it is a matter of great concern that the experiment with methadone will not be succesful in the country, and this may have negative impacts on the acceptance of substitution treatment all around Asia – said Kasia. She called for cooperation from all sides to improve the access to and quality of services for drug users – this was applauded by Mr. Costa as well.

After the panel there was a Questions & Answers session where prominent drug policy experts like Craig Reinarmen, Pat O’hare, Martin Jelsma and Alex Wodak commented on Costa’s speech. They argued that the present course of UN drug policy is proved to be a failure and there are best practices in the local level which show that there are effective alternatives to current prohibition. For example the Netherlands, where the adult population has quasi-legal access to cannabis, but the prevalence rates of cannabis use are relatively low in Europe. Nanna Gotfredsen, head of the Koppenhagen- based NGO Street Lawyers invited Mr. Costa to spend some time in her town, where the „refuges of Swedish drug policy” seek help from services which are not available for them in Sweden. She called Mr. Costa to „abandon his Swedish fantasies” about a drug free society. However, Costa lost his patience in this session and slipped from answering directly to the questions and challanges. He claimed Swedish drug policy to be a success model and he said „the Netherlands is poisoning the rest Europe”.

There was an interesting session on alternatives to prohibition, where scholars discussed the possible ways, modalities and mechanisms of legal regulation of mind altering substances. There is a great diversity of possibilites. Free market regulation is actually supported by a small minority, the majority is in favour of strict limitation of supply and a ban on advertising and selling to underage persons. Speakers emphasized there are many best practices from the regulation of other commodities like alcohol, tobacco and food – these can show how to minimalize effectively the harms caused by drugs in a legalized market.

At the closing session Sam Sullivan, the mayor of Vancouver had a speech in which he described the new developments of harm reduction policies in his town. Mr. Sullivan said drug addiction is neither a criminal/moral nor a medical issue – but it is a management issue, which is similar to physical disabilites. He said as a young man he took high risks with skiing and he became quadriplegic. He got support from the community, he got wheelchair, medications and care. However, his highschool friend, Robert, who took different risks with illegal drugs and became a drug addicted person, did not get any support but he was jailed. Mr. Sullivan said he doesn’t see the moral difference between the two risk taking behaviors, only that Robert didn’t risk the lives of other people with using drugs while he did with irresponsible skiing. Heroine addicts need substitution treatment just as he needs his wheelchair. They are not sick, but they have a management problem which helps them to be functional members of society.

The Norman E. Zinberg Award for Achievement in the Field of Medicine this year was awarded to Kasia-Malinowska Sempruch, acknowledging her tireless work for scaling up science-based services for IDUs all around the world.

Peter Sarosi
Hungarian Civil Liberties Union

Monday, December 03, 2007


In a transcribed interview released by the White House Press Office on 30 Nov, Ambassador Mark Dybul stated: "We do support methadone replacement, which . . . our Institute of Medicine has appropriately said is the most effective way to treat drug users. This is a clinical addiction; it is not a social disease. And there's a clinical treatment with this methadone. And methadone substitution therapy actually is the most effective way to reduce HIV among intravenous drug users, so that's what we support." Click Here for Transcribed Interview

This statement is all the more remarkable since this same Administration's Department of Defense has a written policy (reference on request) that refuses, without exception and without any explanation, to provide health insurance coverage for methadone or other "replacement" maintenance treatments of addiction for any current or former military personnel or their dependents.