Methadone & Other Opiate Maintenance

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Canada: Montreal Heroin Maintenance Study in Doubt after Quebec Refuses to Pay

Fresh on the success of NAOMI, the North American Opiate Maintenance Initiative, in which hard-core heroin addicts in Vancouver were given either methadone, heroin, or Dilaudid in maintenance doses, Canadian researchers announced earlier this year plans to broaden and deeper their research with SALOME, the Study to Assess Long-term Opiate Maintenance Effectiveness. SALOME was supposed to begin this fall in Vancouver and Montreal, but Quebec provincial authorities have thrown a wrench in the works. The Toronto Star reported this week that Quebec has balked on paying its share of the project, stopping the Montreal portion of SALOME in its tracks. The Vancouver portion, supported by the British Columbia provincial government, is set to move forth. Quebec's refusal to pay its share—the Canadian Institutes of Health Research are kicking in $1 million for the three-year project—led Montreal's SALOME head researcher to charge the government with discrimination. The decision will have "disastrous consequences for people addicted to heroin and (who) don't respond to standard treatment," said Dr. Suzanne Brissette, chief of addiction medicine at Saint-Luc hospital. "There is no other treatment for these people." NAOMI showed that heroin maintenance worked for people for whom methadone and other forms of treatment had not, she said. Had researchers found a treatment for cancer or diabetes, Quebec would not hesitate to help fund it, she added. "It's a clear case of discrimination," she said. "We have a treatment that works and they're saying, `Sorry folks, you won't get it.'" NAOMI researchers estimate that Canada has between 60,000 and 90,000 heroin addicts. The NAOMI trials found that addicts on maintenance heroin used less illicit heroin, committed fewer crimes, and adapted healthier life-styles.
Location: 
Montreal, QC
Canada

Feature: Fired Up in Albuquerque -- The 2009 International Drug Policy Reform Conference

Jazzed by the sense that the tide is finally turning their way, more than a thousand people interested in changing drug policies flooded into Albuquerque, New Mexico, last weekend for the 2009 International Drug Policy Reform Conference, hosted by the Drug Policy Alliance. Police officers in suits mingled with aging hippies, politicians met with harm reductionists, research scientists chatted with attorneys, former prisoners huddled with state legislators, and marijuana legalizers mingled with drug treatment professionals -- all united by the belief that drug prohibition is a failed policy.

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candlelight vigil outside the Albuquerque Convention Center (courtesy Drug Policy Alliance)
As DPA's Ethan Nadelmann said before and repeated at the conference's opening session: "We are the people who love drugs, we are the people who hate drugs, we are the people that don't care about drugs," but who do care about the Constitution and social justice. "The wind is at our backs," Nadelmann chortled, echoing and amplifying the sense of progress and optimism that pervaded the conference like never before.

For three days, conference-goers attended a veritable plethora of panels and breakout sessions, with topics ranging from the drug war in Mexico and South America to research on psychedelics, from implementing harm reduction policies in rural areas to legalizing marijuana, from how to organize for drug reform to what sort of treatment works, and from medical marijuana to prescription heroin.

It was almost too much. At any given moment, several fascinating panels were going on, ensuring that at least some of them would be missed even by the most interested. The Thursday afternoon time bloc, for example, had six panels: "Medical Marijuana Production and Distribution Systems," "After Vienna: Prospects for UN and International Reform," "Innovative Approaches to Sentencing Reform," "Examining Gender in Drug Policy Reform," "Artistic Interventions for Gang Involved Youth," and "The Message is the Medium: Communications and Outreach Without Borders."

The choices weren't any easier at the Friday morning breakout session, with panels including "Marijuana Messaging that Works," "Fundraising in a Tough Economy," "Congress, President Obama, and the Drug Czar," "Zoned Out" (about "drug-free zones"), "Psychedelic Research: Neuroscience and Ethnobotanical Roots," "Opioid Overdose Prevention Workshop," and "Border Perspectives: Alternatives to the 40-Year-Old War on Drugs."

People came from all over the United States -- predominantly from the East Coast -- as well as South Africa, Australia, Canada, Europe (Denmark, England, France, Hungary, the Netherlands, Poland, Portugal, Scotland, and Switzerland), Latin America (Argentina, Brazil, Colombia, and Mexico), and Asia (Cambodia and Thailand).

Medical marijuana was one of the hot topics, and New Mexico, which has just authorized four dispensaries, was held up as a model by some panelists. "If we had a system as clear as New Mexico's, we'd be in great shape," said Alex Kreit, chair of a San Diego task force charged with developing regulations for dispensaries there.

"Our process has been deliberate, which you can also read as 'slow,'" responded Steve Jenison, medical director of the state Department of Health's Infectious Disease Bureau. "But our process will be a very sustainable one. We build a lot of consensus before we do anything."

Jenison added that the New Mexico, which relies on state-regulated dispensaries, was less likely to result in diversion than more open models, such as California's. "A not-for-profit being regulated by the state would be less likely to be a source of diversion to the illicit market," Jenison said.

For ACLU Drug Policy Law Project attorney Allen Hopper, such tight regulation has an added benefit: it is less likely to excite the ire of the feds. "The greater the degree of state involvement, the more the federal government is going to leave the state alone," Hopper said.

At Friday's plenary session, "Global Drug Prohibition: Costs, Consequences and Alternatives," Australia's Dr. Alex Wodak amused the audience by likening the drug war to "political Viagra" in that it "increases potency in elections." But he also made the more serious point that the US has exported its failed drug policy around the world, with deleterious consequences, especially for producer or transit states like Afghanistan, Bolivia, Colombia, Mexico, and Peru.

At that same session, former Mexican foreign minister Jorge Castaneda warned that Latin American countries feel constrained from making drug policy reforms because of the glowering presence of the US. Drug reform is a "radioactive" political issue, he said, in explaining why it is either elder statesmen, such as former Brazilian President Cardoso or people like himself, "with no political future," who raise the issue. At a panel the following day, Castaneda made news by bluntly accusing the Mexican army of executing drug traffickers without trial. (See related story here).

It wasn't all listening to panels. In the basement of the Albuquerque Convention Center, dozens of vendors showed off their wares, made their sales, and distributed their materials as attendees wandered through between sessions. And for many attendees, it was as much a reunion as a conference, with many informal small group huddles taking place at the center and in local bars and restaurants and nearby hotels so activists could swap experiences and strategies and just say hello again.

The conference also saw at least two premieres. On the first day of the conference, reporters and other interested parties repaired to a Convention Center conference room to see the US unveiling of the British Transform Drug Policy Foundation publication, After the War on Drugs: A Blueprint for Legalization, a how-to manual on how to get to drug reform's promised land. Transform executive director Danny Kushlick was joined by Jack Cole of Law Enforcement Against Prohibition, Sanho Tree of the Institute for Policy Studies, Deborah Small of Break the Chains, and DPA's Nadelmann as he laid out the case for moving beyond "what would it look like."

"There's never been a clear vision of a post-prohibition world," said Kushlick. "With this, we've tried to reclaim drug policy from the drug warriors. We want to make drug policy boring," he said. "We want not only harm reduction, but drama reduction," he added, envisioning debates about restrictions on sales hours, zoning, and other dreary topics instead of bloody drug wars and mass incarceration.

"As a movement, we have failed to articulate the alternative," said Tree. "And that leaves us vulnerable to the fear of the unknown. This report restores order to the anarchy. Prohibition means we have given up on regulating drugs; this report outlines some of the options for regulation."

That wasn't the only unveiling Thursday. Later in the evening, Flex Your Rights held the first public showing of a near-final version of its new video, 10 Rules for Dealing with Police. The screening of the self-explanatory successor to Flex Your Right's 2003 "Busted" -- which enjoyed a larger budget and consequently higher production level -- played to a packed and enthusiastic house. This highly useful examination of how not to get yourself busted is bound to equal if not exceed the break-out success of "Busted." "10 Rules" was one of a range of productions screened during a two-night conference film festival.

The conference ended Saturday evening with a plenary address by former New Mexico Gov. Gary Johnson, who came out as a legalizer back in 2001, and was welcomed with waves of applause before he ever opened his mouth. "It makes no sense to spend the kind of money we spend as a society locking up people for using drugs and using the criminal justice system to solve the problem," he said, throwing red meat to the crowd.

We'll do it all again two years from now in Los Angeles. See you there!

Heroin Maintenance Comes to Denmark

Heroin maintenance is coming to Denmark. And it's about time -- how about here too? The evidence is in, and it's only ideology that stands in the way of saving lives that now are being needlessly lost. In the meanwhile, watch the video from the Hungarian Civil Liberties Union and the Danish Street Lawyers about the new program:

Harm Reduction: Drug-Related Deaths Rose Dramatically in Recent Years, CDC Says

In a report released Wednesday, the Centers for Disease Control (CDC) has found that drug-related deaths -- the vast majority of them overdoses -- increased dramatically between 1999 and 2006, and that drug-related deaths now outpace deaths from motor vehicle accidents in 16 states. That's up from 12 states the previous year and double the eight states in 2003.

More people died from drug-related causes than traffic accidents in the following states: Massachusetts, New Hampshire, Rhode Island, Connecticut, New York, New Jersey, Maryland, Pennsylvania, Ohio, Michigan, Illinois, Colorado, Utah, Nevada, Oregon and Washington.

The news comes even as harm reductionists and public health advocates seek to gain support on Capitol Hill for passage of H.R. 2855, the Drug Overdose Reduction Act, sponsored by Rep. Donna Edwards (D-MD). The bill would create a federal grant program to support both existing and new overdose prevention programs across the country.

"Patients and their families could receive written instructions on how to recognize and respond to an overdose. In addition, college campuses could utilize overdose prevention money to educate students on how to recognize and respond to an alcohol overdose," advocates for H.R. 2855 wrote in a letter to Reps. Henry Waxman (D-CA) and Frank Pallone (D-NJ), chairmen of the House Energy and Commerce Committee and the committee's Health subcommittee, respectively.

Something like H.R. 2855 is desperately needed. According to CDC researchers, who examined death certificate data from around the country, some 45,000 died in traffic accidents in 2006, while 39,000 people suffered drug-related deaths. About 90% of the drug deaths were classified as overdoses, but researchers also included in that figure people who died of organ damage from long-term drug use.

Researchers reported a sharp increase in deaths tied to cocaine and to the opioid analgesics, a class of powerful drugs, used medically for pain treatment (as well as for non-prescription drug-taking via the black market), that includes fentanyl, methadone, morphine, and popular pain relievers like Vicodin and Oxycontin. Cocaine-related deaths jumped from about 4,000 in 1999 to more than 7,000 in 2006, but methadone-related deaths increased seven-fold to about 5,000, and other opioid deaths more than doubled from less than 3,000 to more than 6,000. Interestingly, heroin-related deaths actually declined slightly, hovering just below 2,000 a year throughout the period in question.

And despite all the alarms about young people dying of drug overdoses, the 15-24 age group had the lowest drug-related death rate of any group except those over 65. Only about three per 100,000 young people died of drug-related causes in 2006, compared to six per 100,000 among the 25-34 age group, eight per 100,000 in the 35-44 age group, and 10 per 100,000 in the 45-54 age group.

CDC researchers did not discuss causes for the increase in overall drug-related deaths or the rate of drug-related deaths.

Overdose and Other Drug-Related Deaths Now Closing In on Car Wrecks as Leading Accidental Killer in US

In a report released Wednesday, the Centers for Disease Control (CDC) has found that drug-related deaths—the vast majority of them overdoses—increased dramatically between 1999 and 2006, and that drug-related deaths now outpace deaths from motor vehicle accidents in 16 states. That's up from 12 states the previous year and double the eight states in 2003. More people died from drug-related causes than traffic accidents in the following states: Massachusetts, New Hampshire, Rhode Island, Connecticut, New York, New Jersey, Maryland, Pennsylvania, Ohio, Michigan, Illinois, Colorado, Utah, Nevada, Oregon and Washington. According to CDC researchers, who examined death certificate data from around the country, some 45,000 died in traffic accidents in 2006, while 39,000 people suffered drug-related deaths. About 90% of the drug deaths were from overdoses, but researchers also included in that figure people who died of organ damage from long-term drug use. Researchers reported a sharp increase in deaths tied to cocaine and to the opioid analgesics, a class of powerful drug that includes fentanyl, methadone, morphine, and popular pain relievers like Vicodin and Oxycontin. Cocaine-related deaths jumped from about 4,000 in 1999 to more than 7,000 in 2006, but methadone-related deaths increased seven-fold to about 5,000, and other opioid deaths more than doubled from less than 3,000 to more than 6,000. Oddly enough, heroin-related deaths actually declined slightly, hovering just below 2,000 a year throughout the period in question. And despite all the alarums about young people dying of drug overdoses, the 15-24 age group had the lowest drug-related death rate of any group except those over 65. Only about three per 100,000 young people died of drug-related causes in 2006, compared to six per 100,000 among the 25-34 age group, eight per 100,000 in the 35-44 age group, and 10 per 100,000 in the 45-54 age group. CDC researchers did not discuss causes for the increase in overall drug-related deaths or the rate of drug-related deaths, but several plausible (and complementary) explanations come to mind: the introduction and widespread use of Oxycontin, the fentanyl-tainted heroin epidemic that appeared in 2006, the increasing non-medical use of prescription pain relievers, and the increasing use of methadone as a pain reliever.
Location: 
Atlanta, GA
United States

A Heroin User in Stockholm

Another video from the Hungarian Civil Liberties Union, this time in partnership with the Swedish Drug Users Union. Sweden's government is one of the world's most prohibitionist, but nevertheless has moved toward harm reduction in recent years by expanding needle exchange into a national policy. Previously needle exchange was happening only in two cities in the nation's south. Well, there's still no needle exchange in Stockholm, according to HCLU, it's even hard to get into a methadone maintenance program, and those who do often face negative attitudes from the program's staff. Check out the video below, or here.
Location: 
Stockholm
Sweden

Feature: Heroin More Effective Than Methadone for Some Addicts, NAOMI Study Reports

In a report that was actually completed last October but not published until this week in the New England Journal of Medicine, researchers from the North American Opiate Medication Initiative (NAOMI) found that giving heroin under supervision to some hard-core drug addicts was more effective than giving them methadone. The study's publication in the prestigious peer-reviewed journal is already leading to calls for experiments with heroin maintenance in the US. To qualify for the study, participants had to have been addicted to heroin, Dilaudid, or another opiate for at least five years, have been injecting for at least the past year, have tried addiction treatment, including methadone maintenance, at least twice, and be at least 25 years of age. While researchers were loathe to generalize their findings, they described heroin maintenance as "a safe and effective treatment" for chronic addicts who have not taken to other forms of treatment.

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Hastings St., downtown Vancouver (from vandu.org)
In the NAOMI project, researchers monitored 251 heroin addicts in Vancouver and Montreal and provided them with maintenance drugs for a year under the supervision of nurses, doctors, social workers, and psychiatrists. One hundred fifteen received pharmaceutical heroin (diacetylmorphine), 111 received methadone, and 25 received Dilaudid (hydromorphone).

Among participants who received heroin by injection, 88% completed the program compared to 54% of those receiving oral methadone. Similarly, illicit drug use rates dropped by 67% among those receiving heroin, compared to 48% among those receiving methadone.

"Our data show remarkable retention rates and significant improvements in illicit heroin use, illegal activity and health for participants receiving injection assisted therapy, as well as those assigned to optimized methadone maintenance," said Dr. Martin Schechter, principal investigator for the Center for Health Evaluation and Outcome Sciences at the University of British Columbia School of Population and Public Health and NAOMI's lead researcher. "Prior to NAOMI, all of the study participants had not benefited from repeated standard addiction treatments. Society had basically written them off as impossible to treat," he said.

"We now have evidence to show that heroin-assisted therapy is a safe and effective treatment for people with chronic heroin addiction who have not benefited from previous treatments. A combination of optimal therapies -- as delivered in the NAOMI clinics -- can attract those most severely addicted to heroin, keep them in treatment and more importantly, help to improve their social and medical conditions," explained Schechter.

The NAOMI research results mirror similar findings from a number of European countries, a fact noted in a Journal editorial by Virginia Berridge. "The results of this trial may be added to those from Germany, the Netherlands, Spain and Switzerland," Berridge wrote. "Switzerland has 10 years of experience in the prescription of heroin, and in a November 2008 referendum, 68% of voters were in favor of its continued prescription."

The NAOMI findings, along with earlier work from Europe, are relevant to the United States. According to government figures, nearly 700,000 Americans are heroin users, and 15% to 25% of them are heavy users who could benefit from prescription heroin.

But heroin is a Schedule I drug under the US Controlled Substances Act, which means it cannot legally be prescribed. That is unlikely to change anytime soon. Even allowing for a pilot program would require political decisions that are unlikely to be made in the foreseeable future.

That needs to change, said advocates of evidence-based drug policies. "The NAOMI results are clear that prescription heroin reduces crime, and overdose deaths," said Laura Thomas, deputy state director of the Drug Policy Alliance. "The reason this effective treatment isn't available in the United States right now is politics. The science is there."

"The success of NAOMI, combined with similar results in other countries, leaves little question that heroin prescription would reduce crime, and overdose fatalities in the United States as well," added DPA executive director Ethan Nadelmann. "Recent votes in Germany and Switzerland, combined with similar evidence of public support in other countries, show that the public will support even controversial drug policies when they have proven results. There is no question that heroin prescription programs are needed and long overdue in this country. All that stands in the way is ideology and the backward assumption that it can never happen in the United States."

It wasn't just DPA wondering about more effective forms of drug treatment. In a blog post titled Prescription Heroin?, New York Times science columnist John Tierney asked just that: Is it time for prescription heroin in the US? He didn't provide an answer, but the fact that the question is being asked by someone like Tierney is suggestive.

And if not prescription heroin, what about Dilaudid? It is Schedule II and can be prescribed, although not, under current law, for maintenance purposes. Schecter and his fellow researchers found that NAOMI participants could not distinguish it from heroin and that it appeared to be equally effective.

Glorious Kyrgyzstan -- the Best Harm Reduction Program in Central Asia

The Central Asian Republic of Kyrgyzstan sits along a drug trafficking route, and has an estimated 80,000-100,000 drug users, more than half of whom inject drugs. Unlike some countries in the region, Kyrgyzstan has embraced harm reduction strategies such as needle exchange and methadone maintenance. Even prisoners in Kyrgyzstan have access to these programs. By going this route, they have been able to curb the country's HIV epidemic. A new video from the Hungarian Civil Liberties Union -- in Russian, with English subtitles -- tells the story. Check it out:

Europe: British Prisons Install Methadone Vending Machines

In a bid to promote opiate maintenance therapy behind bars, the British government has begun installing methadone vending machines in the country's prisons. Justice Minister Phil Hope told parliament last week that 57 vending machines have been installed so far.

The machines allow prisoners to receive an individualized dose of methadone by giving a fingerprint or an iris scan. The machines are paid for by the Department of Health and will cost about $6.5 million dollars, about 10% of the department's prison drug treatment budget. The target is to have the machines in half of Britain's 140 prisons.

According to the latest available prison population statistics, in 2007, nearly 6,400 of Britain's 81,000 prisoners were there on drug charges, with slightly more than half of them charged with simple drug possession or possession with intent to distribute. The official statistics provide no breakdown of which drugs were involved.

"Methadone dispensers are a safe and secure method for providing a prescribed treatment," said a health department spokesman. "They can only be accessed by the person who has been clinically assessed as needing methadone and that person is recognized by a biometric marker, such as their iris."

Providing methadone to addicted prisoners allows them to manage their habits without resorting to illicit heroin supplies within the prisons. But the opposition Conservatives were quick to try to score political points, claiming that the Labor government would rather "manage offenders' addiction" than end it.

"The public will be shocked that Ministers are spending more on methadone vending machines than the entire budget for abstinence based treatments," said Dominic Grieve, the Conservative shadow justice secretary. "Getting prisoners clean of drugs is one of the keys to getting them to go straight. We need to get prisoners off all drug addiction -- not substitute one dependency for another. The government's approach of trying to 'manage' addiction is an admission of failure."

The Conservatives are hammering away at Labor any way they can as they prepare for national elections sometime in the coming months. Attacking enlightened approaches to inmate drug addiction is just another arrow in their "tough on crime" quiver.

Europe: German Parliament Approves Heroin Maintenance

The German parliament has voted to allow the prescription of heroin to addicts who have not responded to other treatments. The lower house of parliament approved the measure May 28.

Under the new law, heroin users who have been using for at least five years, are at least 23 years old, and who have failed to stop in other treatment programs will be able to receive pharmaceutical heroin in designated treatment centers. The law follows a German pilot program conducted in seven cities between 2002 and 2006 that showed impressive results in reducing crime, overdose fatalities, and HIV among hard-core users.

Similar results have been reported in Britain, Canada, the Netherlands, Spain, and Switzerland. Last year, Swiss voters legalized prescription heroin in a public referendum.

The news was welcomed by drug reformers around the planet. "The success of the German heroin prescription projects, combined with similar results in other countries, leaves little question that heroin prescription could reduce crime, HIV and overdose fatalities in the United States as well," said Ethan Nadelmann, executive director of the Drug Policy Alliance. "And [the May 28] vote in Germany, combined with similar evidence of public support in other countries shows that the public will support even controversial drug policies when they are given a chance to prove themselves. There is no question that heroin prescription programs are needed and long overdue in this country. All that stands in the way is politics and the backward assumption that it can never happen in the United States."

The Australian group Families and Friends for Drug Law Reform likewise used the German vote to agitate for similar policies Down Under. "The German decision challenges Australia to remove John Howard's veto of this medical treatment and put humanity and social well-being first," said Brian McConnell, President of Families and Friends for Drug Law Reform. "The veto of the decision of the Australian Health Ministers in 1997 for a heroin trial must be reviewed in the light of the rising number of overdose deaths and the threat of a renewed flood of Afghan heroin," he said

"Excuses for not introducing it have become baseless given the overwhelming evidence that now exists in support of the measures," McConnell added. "Attracting the severely addicted into treatment, away from recruiting and selling to new users to support their habit, will surely allay parents' and governments' concerns about the provision of this treatment. It can undermine organized crime's profit from heroin, which is critical at a time when world production of heroin is increasing. Much is to be gained with this common sense measure: there are lives to be saved, individuals' health to improve and a huge potential for reduced crime and trafficking in illegal heroin."

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