Sober N Clean

By giving drug addicts a sterile syringe and a warm place to shoot up, are we saving lives or condoning substance abuse?

To illuminate the double standard surrounding "harm reduction," Dr. Stephen Hwang, a medical researcher and associate professor of medicine at the University of Toronto, offers the following scenario:

Suppose that an innovative but controversial intervention is launched to reduce complications of Type 2 Diabetes, and 7,000 subjects take part in a trial. Researchers, funded by Health Canada to study the intervention's effectiveness, find that while not curing diabetes, the intervention improves health, reduces infections and prevents premature deaths -- with no adverse effects. The findings are published in the world's leading medical journals.

But the federal government deems the findings inconclusive and says the only acceptable therapies for diabetes are those that either prevent or cure the condition -- even though no such therapies exist. Columnists, community leaders and national organizations expound that the intervention "enables" bad lifestyle choices, and that without the dire complications of diabetes, people with the condition would eat more, exer cise less and become increasingly obese. And those who didn't have diabetes would forgo healthy diets and exercise because they'd no longer fear the disease. The government considers banning the intervention.

Sound far-fetched? Not, says Hwang, if you replace the word diabetes with drug addiction, and the word intervention with Insite, the safe-injection site pilot project that began in Vancouver's Downtown Eastside in 2003. Insite has allowed addicts to inject drugs under secure, clean conditions, and all under the supervision of a nurse.

"I wanted people to see how hypocritical we are in the way that we treat two chronic conditions that have a lot of associated harms," says Hwang. A specialist in inner-city medicine, he wrote the diabetes scenario for the peer-reviewed online journal Open Medicine, arguing that when it comes to drug abuse, ideology trumps science in a way that would not be tolerated with other chronic health conditions. Hwang's treatise was endorsed by more than 130 prominent Canadian scientists, doctors and public-health professionals.

Think there's a huge difference between drug addiction and diabetes? There isn't, says Hwang: Both arise through a complex mix of predisposed genetic and environmental factors -- triggered by lifestyle choices, behaviour and bad luck -- that result in disorders of body chemistry. Both have potentially severe complications, such as infections or premature death, that can be reduced with good medical care. Just as some addicts can kick their addictions, some people with diabetes, through weight loss, gastric bypass surgery or extreme exercise, can eliminate their symptoms and their need for medication -- though drug-free addicts and insulin-free diabetics both risk relapse. Yet do we refuse to treat the health complications of people with diabetes who cannot wean themselves off medication? Never.

"A heroin addict needs heroin as much as a diabetic needs insulin," says Norm Stamper, a former chief of the Seattle police department. "That need is real. It is physiological." After witnessing the failure of the United States' strict "war on drugs" to stem narcotic use and its associated problems, Stamper is now a leading advocate of safe-injection sites, methadone-treatment, needle-exchange and other harm reduction programs that aim to refocus efforts from policing to medical management.

Here's what more than 20 studies --all by independent evaluators, published in prominent journals -- have found: Insite has reduced instances of needle sharing and drug injecting in public places, and there has been a decrease in the amount of injectionrelat ed litter. In the Insite neighbourhood, there have been no increases in drug trafficking or assaults, and instances of vehicle break-ins and car theft have decreased. Despite almost 900 overdose events at Insite -- a common hazard of drug use -- no overdose deaths have occurred at the facility, compared with an average of 60 a year in Metro Vancouver. Additionally, since Insite began, the number of drug addicts who have entered detox programs, addiction counselling and drug-addiction treatment has increased by over 30%.

Dr. Perry Kendall, the B. C. Health Officer, says opposition to Insite is not based on evidence of effectiveness but on the notion that drug addicts have made bad choices and must change or live with their fate. "The belief," he says, "is that if health providers remove or lessen the harms of addicts' behaviour, addicts won't hit bottom and therefore won't have the motivation to go clean."

"The issue is not whether the addict would be better off without his addiction--of course he would--but whether we are going to abandon him to illness or death if he is unable to give it up," says Dr. Gabor Mate, who has served as staff physician at Insite and is the author of In the Realm of Hungry Ghosts: Close Encounters with Addiction. Mate's book is a must-read for those who reject harm reduction as "coddling" drug addicts or who believe "Just Say No" is a realistic policy. In his book, Mate shows his patients' struggles and demons, how they became addicts and how they found a way out. The book illus trates a central premise of HR: accepting those with drug addictions and trying to move them along the continuum to better health -- keeping them alive and well long enough to have a chance to quit later.

Some who were once adamantly against Insite have come to support it. One such person is George Chow, former president of the Chinese Benevolent Association of Vancouver. Chow successfully ran for city councillor on a ticket of rejecting Insite -- the centre was on China town's doorstep -- gathering some 18,000 signatures from the Chinese community. Yet, after Insite had been in operation for three years, he changed his mind. "I am keenly aware of the debate surrounding [Insite]. But I am pleased to say that the initial fears of the community -- a potential increase in crime and public disorder -- have not materialized," Chow wrote in a letter to Prime Minister Stephen Harper in the fall of 2007.

If only more of us were willing to change our positions based on evidence, we might finally begin to make progress against this terrible affliction called drug addiction.
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source: The National Post, http://www.nationalpost.com

WASHINGTON — The Bush administration underscored its continued support for Afghan President Hamid Karzai on Thursday despite fresh allegations from a former U.S. anti-drug official that Karzai is playing both sides of the effort to combat a raging drug business.

Thomas Schweich, who until June was one of the State Department's senior counter-narcotics officials, accused Karzai of protecting drug lords for political reasons. Schweich wrote in an article to be published Sunday in The New York Times magazine that "narco-corruption went to the top of the Afghan government."

Schweich said the Taliban-led insurgency fighting Karzai's government profits from drugs, but Karzai is reluctant to move against big drug lords in his political power base in the country's south, where most opium and heroin is produced.

"Karzai was playing us like a fiddle," Schweich wrote. The article appeared on the Times' Web site late Wednesday.

"The U.S. would spend billions of dollars on infrastructure development; the U.S. and its allies would fight the Taliban; Karzai's friends could get richer off the drug trade," he wrote.

State Department spokesman Gonzalo Gallegos did not directly address Schweich's allegations but defended U.S. policy and backing for Karzai.

"We know and understand that there is a corruption issue in Afghanistan but we're working with the sovereign government," Gallegos said Thursday. "President Karzai has shown us through word and deed that he is working with us to help improve the plight of that country."

Corruption is a deeply rooted problem and addressing it, along with the country's massive development need, will not be quick, Gallegos said. "This is a long-term commitment in terms of time and this is a large commitment in terms of dollars."

Afghan officials were not immediately available to respond to Schweich's allegations.

Drug production has skyrocketed since the U.S.-led invasion that ousted the Taliban regime. In 2007, Afghanistan produced 93 percent of the world's supply of opium, the raw material of heroin.

Karzai has repeatedly promised his U.S. backers that he is committed to rooting out endemic corruption and fighting the drug trade.

"Karzai had Taliban enemies who profited from drugs but he had even more supporters who did," wrote Schweich, who used to serve as coordinator for counter-narcotics and justice reform for Afghanistan. He was based in Washington.

Presidential elections in Afghanistan come next year, and Karzai has indicated he'll seek re-election.

Schweich accused the Pentagon and some U.S. generals of obstructing attempts to get military forces to assist and protect opium crop eradication drives.

NATO and U.S. military commanders have been reluctant to get involved in the drug fight, arguing that destroying farmers' crops would alienate tribesmen and increase support for the Taliban.

In 2003, about 198,000 acres of land was used to cultivate poppy. By 2007, it rose to 476,900 acres.

Opium production topped 9,000 tons, enough to make over 880 tons of heroin with a street value of $4 billion, according to the United Nations.

Figures for 2008 are not yet available.

The Ministry of Counter Narcotics says that 20 of Afghanistan's 34 provinces will be poppy-free this year — compared with 13 provinces in 2007. But in the south, cultivation remains rampant.
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source: e-ariana.com

Drug-users tend to die young, but we know surprisingly little about those who survive the dangers of overdose or violence to which their lifestyle makes them susceptible. A study of a group of injecting heroin-users in Edinburgh reveals that even those who stop the most dangerous forms of behaviour remain at risk.

Drug-related deaths in Scotland reached a record high in 2006 and a recent report by the UN showed that Scotland has almost twice as many drug-related deaths (at 8.2 per 100,000) as the rest of the UK and comparable European countries. The Edinburgh research, carried out over 10 years from the mid-1980s to the mid-1990s, found that more than half the users were HIV positive and that Aids-related illness was replacing overdose as the main cause of death. That is largely due to a switch from injecting heroin to oral drugs, both prescribed (including methadone) and illegally-obtained ones. Despite this, however, the overall mortality rate among drug-users and former users will remain high owing to Aids. There are other worries attached to their behaviour, including a high number of sexual partners, with HIV now more likely to be acquired by sexual transmission than by sharing needles.

The study confirms the other bleak long-term effects of drug use. Two-thirds of the group had at least one child, but the majority of the men and 16% of the women did not live with their children, resulting in those who could not be cared for by the other parent going to grandparents, being adopted, fostered or in residential care.

This research (carried out among patients in Muirhouse, an area with a high concentration of deprivation) is published as Audit Scotland is investigating the effectiveness of drugs policy in Scotland, in particular the £12m a year spent on the methadone programme. According to the Edinburgh researchers, however, the decrease in injecting predated the policy of prescribing methadone and they suggest an increase in sentences both for dealers and people found in possession of heroin, which "disrupted an active drug-using community" was an important factor.

Their conclusion, that drug-users require long-term support for a multiplicity of problems, follows a green paper from the Westminster government which suggests that drug addicts on long-term benefits should be required to attend treatment and rehabilitation programmes. That is easier said than done: only 18% of the group abstained completely from drugs during the course of the study, while 21% had periods of abstinence and relapse. At a time when 50,000 people in Scotland have a problem with heroin or other opiates, and proposals on how to reduce associated problems include drug consumption rooms, or "shooting galleries" where intravenous users can inject in a safe environment, a coherent, effective drugs policy is urgently required. This study stands as a warning that there are no short-term solutions.
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source: The Herald, http://www.theherald.co.uk

World donors promised Afghanistan more than $20 billion (£10 billion) of new aid, plus fresh moral support, yesterday, but told President Karzai that they were losing patience with his Government’s failure to stem rampant graft and drug trafficking.

Under international pressure over the lack of progress in rebuilding his country, Mr Karzai promised to fight corruption and sought understanding. Poppy-growing farmers, for example, needed help, he said. “Opium is about survival for them.”

The United States, represented by Laura Bush, its First Lady, opened the pledges at the Paris donors’ conference with a $10.2 billion commitment over five years. “Afghanistan has reached a decisive moment for its future. We must not turn our back on this opportunity,” she said.

David Miliband, the British Foreign Secretary, promised £600 million. He praised progress made in security and healthcare but said that there was a long way to go in building good governance in Afghanistan. The growing links between the insurgency and the drugs industry - which, Mr Miliband said, was reflected in the haul of 235 tonnes of cannabis resin worth about £200 million - had to be tackled.

The total was well short of the $50 billion that Mr Karzai was seeking from the 80 nations and organisations that have already promised $25 billion since 2002. Only $15 billion of that has been spent so far, much of it ineffectively and wastefully, according to aid experts. Afghanistan depends on aid for 90 per cent of its needs.

Nevertheless, Bernard Kouchner, the French Foreign Minister, called the conference “an unexpected success”. “We had hoped in our most optimistic moments to raise perhaps 17 billion at the most,” he said.

President Sarkozy of France led a chorus of support for Mr Karzai’s fragile Government as the best hope for Afghanistan. “It is the duty of all democrats to help you,” he said. Mr Sarkozy, who has deepened French engagement with the forthcoming deployment of 900 combat troops, said that Afghanistan “was taken hostage by a regime allied to terrorism”.

About 8,000 people were killed last year in the fight with a rejuvenated Taleban, which is trying to break Western will to keep the Nato-led force of 47,000 in Afghanistan.

Ban Ki Moon, the UN Secretary-General, called for “active measures” against corruption, more transparency and better management of aid.

Stephen Smith, the Australian Foreign Minister, said that reconstruction had been slow. Mr Smith told The Times that “the Afghan Government has to start taking some responsibility” for the administration of the aid funds.

Mr Karzai cited progress in building roads and hospitals, and in fighting opium production since the 2001 fall of the Taleban regime, but he acknowledged: “There is a long way still ahead of us . . . Afghanistan needs adequate, long-term and predictable support.”
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source: http://www.timesonline.co.uk

It is unusual for politicians to face up to the obvious, but the Scottish Executive seems for once to have done so: it has recognised what has long stared it in the face, namely that dishing out methadone to drug addicts is not the answer to their problems or to the problems that they cause society. A different approach is needed.

Perhaps in 100 years historians will wonder why so many of the governing elite, from senior doctors to Cabinet ministers, persisted for so long in the belief that doling out methadone was the answer. The explanation, I think, will be that they wilfully misunderstood the nature of the problem.

Many years ago I used to dole out methadone like the best (or the worst) of them. This was before I thought at all deeply about the question of drug addiction and accepted uncritically all that I had been taught about it by doctors senior to me. I began to change my opinion when I worked in prison where it was the clinical policy to give addicts methadone. I noticed that, far from creating an atmosphere of contentment and satisfaction, it created one of perpetual tension and irritation. Shortly after having been prescribed a dose, the prisoner would return and say, in an intimidating fashion: “It's not holding me, doc, it's just not holding me,” and sometimes announce that, unless he was prescribed more, he would end up attacking other prisoners, and then it would be the doctor's fault.

In Scotland the great majority of addicts prescribed methadone by their doctors never stop taking it, and most of them take other drugs as well. A particularly dangerous combination of drugs is methadone and benzodiazepines (drugs such as Valium), and yet drug clinics and other doctors persist in prescribing this often fatal combination - largely, I suspect, because they are too frightened of their patients to refuse them anything.

The number of people admitted to hospital having taken a dangerous overdose of methadone (556 in 2006-07) is greater, proportionately, than the number of people admitted to hospital having taken a dangerous overdose of heroin (1,530 cases). In Dublin recently, more people have died of methadone poisoning than of heroin overdose. The supposed cure causes as many problems as the supposed disease. If addicts prescribed methadone are given the opportunity to divert it on to the black market, they will: which suggests that they do not really need it in the first place.

In France, addicts are often prescribed a different drug, buprenorphine, which soon became the street drug of preference in Finland, to which it was illegally re-exported by the addicts. More recently, a huge epidemic of buprenorphine addiction has occurred in Georgia (the ex-Soviet republic), numbering scores of thousands of addicts, who take buprenorphine diverted from France. If the addicts really needed the drugs, they would take them rather than divert them on to a black market.

In the prison in which I used to work, a buprenorphine tablet that had been prescribed for an addict to alleviate the symptoms of withdrawal from heroin on arrival in the prison, and which an addict had put in his mouth and spat out for sale to another prisoner, was known as a “furry” because of its rough surface. Again, this suggests that addicts did not really need what they were prescribed, and that the whole basis of prescription was flawed.

The fundamental error that the Scottish Executive has now admitted is in having regarded addiction to heroin as a technical medical problem, to be solved by technical medical means. But that old approach amounts to a surrender to blackmail: give me what I want or I will continue to behave badly and to hold you responsible for the ill-effects of my own behaviour.

Suppose we gave money to burglars to induce them to stop burgling. No doubt most of them would stop for a length of time depending upon how much we gave them. But this does not mean that money is the treatment of the dreadful disease of burglary, or because we prevented certain individuals from continuing to burgle it means that we had reduced the disease of burglary in society as a whole. Rather, we would have encouraged its spread.

This is precisely the logic that has been applied to drug addiction. Just how precisely is evident from the Government's recent declared policy that clinics should now give drug addicts money or other rewards for not taking drugs (as least as proved by drug-free urine samples, something experienced drug addicts have long learnt to provide). This is the first time in the history of medicine, so far as I know, that bribery has been considered a medical treatment.

Contrary to what everyone supposes, withdrawal from heroin is not a serious medical condition - unlike, say, withdrawal from alcohol when it results in delirium tremens (the DTs). The suffering is grossly exaggerated and, in so far as it is genuine, is largely produced by anticipatory anxiety that is itself the consequence of years of mythologising the fearsomeness of withdrawal.

Addiction to heroin is a medical problem only to a minor extent, which is why predominantly medical means will never solve the problem. Most of Britain's 300,000 addicts are drawn from broken families, have a poor education, are without much hope for (or for that matter fear of) the future and have no cultural life, intellectual interests or religious belief. Delusory euphoria - the paradise at three pence a bottle that De Quincey described in his Confessions of an English Opium Eater - is the best that they think that they can hope for in life. This is not a medical problem. Where addiction is concerned, it is time to throw physic to the dogs.
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author: Theodore Dalrymple is a retired prison doctor and author of Junk Medicine: Doctors, Lies and the Addiction Bureaucracy

source: Times Online

Taxpayers have footed a £1 million compensation bill after almost 200 drug-addicted prisoners sued the Government, claiming that denying them a heroin substitute breached their human rights.

The prisoners claimed that their rights were infringed when they were deprived of methadone and had to go “cold turkey”.

A High Court test case involving six prisoners was going ahead two years ago but the Government agreed to settle out of court and pay £750,000 to 197 inmates in jails in England and Wales.

The compensation payments averaged £3,807 per prisoner, with four in Wymott jail in Lancashire receiving a total of £15,228 and three at Preston prison £11,421.

The overall bill to the taxpayer of £1 million includes the compensation payments plus the estimated lawyers’ fees.

The Government decided against fighting the compensation claims to minimise costs. It had been warned that if the case had gone to court the prisoners could have won even larger amounts of compensation.

The prisoners had been using methadone paid for by the Government but it was decided that they should go through cold turkey detoxification instead. They claimed that their human rights had been breached under Articles 3 and 14 of the European Convention on Human Rights, which bans discrimination, or inhuman or degrading treatment or punishment.

At the preliminary hearing in 2006 Richard Hermer, a human rights lawyer specialising in group actions against the Government, told the court: “Many of the prisoners were receiving methadone treatment before they entered prison and were upset at the short period of treatment using opiates they encountered in jail. Imposing the short, sharp detoxification is the issue.”

The addicts said that their treatment was handled “inappropriately” with the consequence that they “suffered injuries” and had “difficulties” with their withdrawal. They claimed that the treatment constituted trespass and accused the Prison Service of clinical negligence.

A Prison Service spokeswoman said that the payments made were in response to a minority of the claims. “We successfully defended the majority of claims. We make payments only when we are instructed to do so by the courts or where strong legal advice suggests that a settlement will save money,” she added.

Latest figures show that compensation payments to prisoners have fallen from a total of £4.4 million in 2005-06 to £2 million in 2006-07.

source: Times Online

I am 19 and I am a heroin addict. I’ve been through drug programs four times and have been clean since October.

I’m very together at the moment, so these are not just the ramblings of a doped-up junkie.

Firstly, heroin has been a big problem in Cape Town for a long time. I cannot imagine that people are only starting to notice it now. It has been targeted at people a lot younger than in their twenties. In fact, my friends and I have been doing drugs from about the ages of 12 – 15.

Detox not for the fainthearted
Getting off the stuff is not easy - detox plans in South Africa are revolting. During my first detox in a treatment centre, I was simply locked in a room for three days. After a while, I started having epileptic fits and foaming at the mouth. This happens to many people who are mainliners (those who inject drugs intravenously). The staff held me down on a bed and told me to think happy thoughts. There was no appropriate detoxification medication available.

I was clean for 9 months before I relapsed and overdosed. My sister found me dying and took me to hospital.

Hospital care not very caring
I must say that I don’t think the hospitals have any time for people like us. The next day the doctor came and just looked at me and without saying a word, signed my release forms. I had to spend the night, because my heart had stopped. I was in withdrawal, but that didn’t stop them from simply kicking me out of the hospital.

Is it my own fault that I am this way? Would anyone choose this willingly? Many people don’t seem to understand that we cannot help who we are and that we never asked to be like this. Yes, we do know that we made a choice, the consequences of which we live with every day, but that doesn’t mean we are any less human.

The places in South Africa that are equipped to deal with heroin addiction are few and far between. And some of them are very expensive. So what happens if you’re not a member of a medical scheme? But wherever you go, the sacrifice is worth it. After all, you get your life back.

source: http://www.health24.com/

THE biggest study of heroin and cocaine abuse in years has been launched amid new indications that Scotland's drugs crisis is now worse than ever.
The Scotsman understands that the number of people who died from drug overdoses last year is likely to be well over 400, and could be the highest ever.

There were 421 drug-related deaths recorded in 2006, a record figure that compared with 336 the previous year.

The need for toxicology reports to confirm causes of death means the final 2007 figure will not be known for some months. But The Scotsman understands that by the beginning of October the figure was about 20 higher than that for the same period the previous year.

It had been hoped that the unusually high number of drug deaths in 2006 would turn out to be a blip, but the indication that the number of deaths last year is likely to be even higher has raised serious concern that it could be part of a trend.

The Scottish Government has now commissioned a massive study into the number of heroin and cocaine users.

The study, which is costing about £175,000 and will be led by Dr Gordon Hay, from the Centre for Drug Misuse Research at Glasgow University, is the first of its kind since 2003.

That research concluded that there were 50,000 serious drug users in Scotland – about 1 per cent of the population.

But nobody knows what the current scale of class A drug use is. Experts say this is hampering action to tackle a drugs problem that is among the highest in western Europe.

Dr Neil McKeganey, the centre's director, yesterday called for an independent review of drug misuse.

"If the drug death figures show an increase on the previous year, or are even on a par with 2006, it really must generate a very detailed review of the thrust of our drug treatment services in Scotland," he said.

Tom Wood, chairman of the association of drug action teams in Scotland, warned it would take years to turn around the number of drug deaths.

"It's going to be difficult to envisage a great reduction in drug deaths in the next year or so because the people who are dying are dying at the end of a substantial career of drugs use. The typical profile is a 38-year-old man who has a ten year history of drug and alcohol abuse.

"They're usually not dying because of what they did yesterday, they're dying because of what they did for the last ten years."

A spokesman for the Scottis
h Government said: "We are determined to ensure better quality data and recording systems to monitor and evaluate best practice in treatment.

"We also want to see the development of a more robust national evidence base."

GRIEVING SISTER URGES HELP

THE sister of a man who died from a heroin overdose called yesterday for more support for addicts.

Kevin Morgan, 30, was found dead in the toilets of a McDonald's in Edinburgh last September, days after he was released from a short prison sentence for stealing to fund his habit.

Tracey Johnston, 36, of Gifford, East Lothian, said her brother's life had spiralled downwards following the death of their mother. She said: "The prisons are getting better at stopping drugs getting in, but I don't think there's enough support when they come out. He was just a lost soul. He had a heart of gold when he wasn't on drugs."

source: The Scotsman