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Drug War Chronicle Book Review: "In the Realm of Hungry Ghosts: Close Encounters With Addiction," by Dr. Gabor Maté (2010, North Atlantic Books, 468 pp., $17.95 PB)

Phillip S. Smith, Writer/Editor

In the revised edition of his prize-winning Canadian best-seller, Vancouver's Dr. Gabor Maté has made an important contribution to the literature on drug use and addiction. For more than a dozen years, Maté has been a staff physician for the Portland Hotel Society in Vancouver's infamous Downtown Eastside, home to one of the hemispheric largest, most concentrated populations of drug addicts. The Portland is unique -- once just another shoddy Skid Row SRO, under the management of the Society it is now both a residence for the hardest of the hard-core and a harm reduction facility.

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As a medical resident at the Portland, Maté has seen it all. The first section of "Hungry Ghosts" is filled with descriptions of his patients and their lives. Much of this is quite literally horrendous: Coked-out women turning tricks in alleys for their next rock and contracting syphilis; suicidal, opiate-addicted women refusing HIV treatments; mentally ill and alcoholic men dying young of liver cancer from Hepatitis C infections; people strung out on crack scrabbling at pieces of gravel on the sidewalk in the hallucinatory hope it's another rock; multi-addicted men and women, blood oozing from festering sores as they search yet again for a vein to hit, people overdosing and then going right back at it, people overdosing and dying.

And yet, despite the misery they are in and the wrecks that are their lives, they keep on using. "Hungry Ghosts" is an extended meditation on why. The second chunk of the book is devoted in particular to addressing that question. Maté offers an extended tour of the latest research into the disease model of addiction, with succinct and understandable (to the layperson) explanations of reward circuits in the brain, dopamine and serotonin flows, and all that good neuro-bio-pharmacological stuff so beloved of NIDA grantees. Repeated use of a substance indeed "rewires" the brain, creating pleasure circuits demanding to be fulfilled and pleasure deficits demanding to be fixed... with that next fix.

But unlike the NIDA people, with what I consider to be their neuro-bio-pharmacological determinism and reductionism, Maté goes a step further. He points out, accurately enough, that no matter what substance we're talking about, only a fraction of users, typically between 10% and 20%, become addicts. The "chronic relapsing brain disease" model may have some utility, but it fails to explain why some people are susceptible to addiction in the first place and others are not.

Maté noticed something about his downtrodden, strung-out clientele in Vancouver. They were almost universally abused as children, and at best, neglected. And I mean abused: Not spanked too hard, but raped, beaten, raped again, exploited, sent into foster care, literally spit on by their parents. It's very ugly.

One story especially sticks with me. A First Nations woman whose mother lives on the Downtown Eastside was given up at birth by her addicted mother, and sent to live with relatives, several of whom repeatedly sexually molested her in especially disgusting ways. She grew up an angry, depressed kid who turned to drugs and drink early. Tired of her life, she saved up $500 when she was 14 and ran away to Vancouver to find her mother. She did find her mother -- too bad for her. Mommie dearest promptly shot her up with heroin, spent the $500 on drugs for herself, then turned her out to turn tricks on the street. And you wonder why this woman prefers a narcotized bliss?

Maté doesn't just rely on anthropology and anecdote. He takes the reader instead into an extended look at the research on early childhood development and identifies messed-up childhoods as the key indicator of future substance abuse (as well as many other) problems. It doesn't have to be as extreme as some of these cases, but Maté makes clear that a nurturing early up-bringing is absolutely vital to the development of mentally and emotionally stable human beings.

Maté also has a startling confession to make: He, too, is an addict. The good doctor has been fighting a lifelong battle with his addiction to... wait for it... buying classical music CDs. He has behaved just like a junkie, he admits, spending thousands of dollars on his habit, lying to his wife, neglecting his kids, even leaving in the middle of medical procedures to run and score the latest Vivaldi. He's suffered the same feelings of compulsion, guilt, disgust, and self-denigration as any other addict, even if he doesn't have the scars on his veins to show for it.

At first glance, Maté's claim almost seems ludicrous, but he's making an important point: Addiction is addiction, whether it's to heroin or gambling, cocaine or shopping, he argues. The process of changes in the brain is the same, the compulsion is the same, the negative self-feelings are the same. We don't blame playing cards for gambling addiction or shopping malls for shopaholism; similarly, drugs are not to blame for drug addiction -- our own messed up psyches are the root of the problem.

And that leads to another important point: Those hollow-eyed addicts are like the rest of us, they are a dark mirror on our own inner problems, and most of us have some. (I'm reminded of a cartoon I once saw of a man sitting by all alone in an empty auditorium under a hanging banner saying, "Welcome to the convention of children of non-dysfunctional families.")

This is important because it stops us from dehumanizing drug addicts. They are not "the other." They are us, different only in degree. They deserve caring and compassion even if it is tough and seemingly fruitless work. Maté chides himself for falling from that saintly pedestal on occasion, and good for him.

Not surprisingly, Maté is a strong advocate of harm reduction and a harsh critic of prohibitionist drug policies and the US war on drugs in particular. By grinding drug users down even further, prohibition serves only to make them more likely to seek solace in chemical nirvana. It's almost as if prohibition were designed to create and perpetuate drug addiction.

In the final chapters of "Hungry Ghosts," Maté offers a glimmer of hope for beating drug addiction (or gambling addiction or sex addiction or whatever your particular compulsion is). It is a tough path of self-awareness and spiritual practice. I don't know if it will work -- I haven't tried it myself -- but it is important to remind ourselves that addiction is not necessarily a hopeless trap with no escape.

This is good, strong, compassionate, highly informed reading. I heartily recommend this book to anyone with an interest in addiction, addiction treatment, early childhood development, or drug policy. Thanks, doc.

Tainted Supply: Cocaine Laced With Levamisole Keeps Turning Up

Back in September, we reported on the appearance of cocaine cut with levamisole, a veterinary de-worming agent, and its links to at least three deaths in the US and Canada from a disease caused by levamisole, agranulocytosis. At that time, the DEA reported that levamisole was turning up in about 30% of the cocaine it sampled.

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DEA levamisole findings
Now, the DEA says that figure is up to 70%. While the number of fatalities has remained unchanged since last fall, new cases of agranulocystosis continue to appear in North American drug users. Earlier this month, authorities in Winnipeg, Manitoba, reported that two cocaine users contracted the disease there and that additional cases had been reported in neighboring Alberta.

Levamisole suppresses immune function and the body's ability to fight off even minor infections, and people who ingest levamisole-tainted cocaine can be faced with quickly-developing, life-threatening infections. Agranulocytosis is a condition of suppressed immune systems. Its symptoms include chills or high fever, weakness, swollen glands, painful sores, sudden or lingering infections, skin infections, abscesses, thrush, and pneumonia.

Cocaine contaminated with levamisole, although not users with agranulocytosis, has also popped up in the last few days in Maine and Ohio. Samples of crack cocaine in Mansfield, Ohio, tested positive late last month. And public health officials reported Tuesday that 30% to 50% of Maine cocaine samples tested positive.

The Substance Abuse and Mental Health Services Administration (SAMHSA) put out an alert late in September warning of the tainted cocaine, but federal authorities have done little publicly since then.

Given the geographically widespread reports of cocaine contaminated with the veterinary drug, it is assumed that levamisole is being added as a cutting agent either in source countries or in transit countries, not by local dealers.

Feature: Anthrax-Tainted Heroin Takes Toll in Europe, Prompts Calls for Emergency Public Health Response

European heroin users are on high alert as the death toll rises from heroin tainted with anthrax. At least eight people have died -- seven in Scotland and one in Germany -- since early December, and another 14 Scottish heroin users have been hospitalized after being diagnosed with anthrax. Meanwhile, drug reform and drug user activists are reporting a cluster of nine suspicious heroin-related deaths in Coimbra, Portugal, although it is unclear at this point whether they are linked to anthrax-tainted heroin.

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anthrax spores
The Scottish government has responded by urging heroin users to stop using and to seek drug treatment. That advice has not gone over well with drug users and public health and harm reduction advocates, who are demanding an emergency public health response.

The first four Scottish deaths were in Glasgow, but after one person died in Tayside and one in the Forth Valley earlier this month, Health Protection Scotland epidemiologist Dr. Colin Ramsay said: "The death of this patient in NHS Forth Valley indicates further geographical spread of the cases, meaning that heroin users all across Scotland need to be aware of the risks of a potentially contaminated supply. I would urge all users to stop using heroin immediately and contact local drug support services for help in stopping. If any heroin users do notice signs of infection, for example marked redness and swelling around an injection site or other signs of serious infection such as a high fever, they should seek urgent medical advice."

The French government has also reacted, with the General Directorate for Health issuing a statement Tuesday warning that contaminated heroin may be circulating in France and other European countries. Noting the rising death toll, the statement said "the likeliest source is heroin contaminated by anthrax spores."

Heroin users should be alert, the French statement said, because heroin contaminated with anthrax is indistinguishable from other heroin. "There is no outward sign or color enabling the user to tell whether the heroin has been contaminated by anthrax, and contaminated heroin dissolves or is used in the same way as uncontaminated heroin," it said.

Anthrax is a potentially lethal bacterium that exists naturally in the soil and can also occur among cattle. It is also a potential bio-terror weapon.

The vast majority of heroin consumed in Europe comes from Afghanistan, and while so far evidence is lacking, speculation is that anthrax spores may have been present in bone meal, an animal product sometimes used as a cutting agent. Another possibility is that containers used in the heroin production process were contaminated with anthrax spores. And, given fears that Al Qaeda and its Taliban allies could resort to biological warfare against the West and given the Taliban's role in the Afghan opium and heroin trade, a bio-attack cannot be completely ruled out.

"The anthrax-infected heroin hasn't decreased use, whether people are injecting it or chasing [smoking] it," said Tam Miller, chair of Chemical Reaction, an Edinburgh drug user group, and a member of INPUD (the International Network of People who Use Drugs). "People are scared -- you can be sure of that -- but I think they're more afraid of withdrawing. The Scottish government's advice was for people to stop using heroin, but that won't happen."

Instead, Miller said, heroin users are doing what they can to protect themselves. "Users feel there's not much they can do personally and, as usual, they feel isolated," he said. "A lot are looking up the effects on anthrax on the net and passing on information to people with no internet access. We think the powers that be should put out information on how to spot signs if someone has been in contact with access. Basically, mate, the Scottish government wants little to do with it."

The Scottish government's response so far has drawn a harsh rebuke from the United Kingdom's harm reduction and public health community. In a Tuesday letter to the Scottish government, the International Harm Reduction Association, the drug think tank Release, the Transform Drug Policy Foundation, the UK Harm Reduction Alliance, and individual public health experts called on the government to put in place an emergency public health plan to deal with the crisis.

The letter said the government's advice to heroin users to stop using and enter treatment was "reckless in light of the fact that waiting times in Scotland for opiate substitute treatment (OST) are the longest in the UK. Many of those accessing services are informed that it is a condition of their treatment to engage with the service for a minimum period of time, before they will be entitled to a prescription offering an alternative substitute medication, usually methadone. In some areas of Scotland we have been informed that waiting times for OST can be up to 12 months."

[There is another potential issue with methadone, as well. The antibiotic drug Cipro, used to treat anthrax, interacts with methadone, leading to the possibility of methadone overdoses.]

Given the reality of treatment shortages and delays, it is "unacceptable" for the Scottish government to just tell users to stop or to go to treatment that isn't there, the letter said. "It is clear that this kind of approach can only lead to the death of more vulnerable people."

Instead, the Scottish government must immediately implement a public health plan that includes rapid access and low-threshold prescribing of alternatives to street heroin, the letter-writers advised. They recommended prescribing dihydrocodeine, a synthetic opiate approximately twice as strong as codeine. It is sold in the US under brand names including Panlor, Paracodin, and Synalgos.

"Such an approach will go some way to prevent any more loss of life and will provide greater protection to the public as a whole," the letter said. "Failure to adopt such a policy would mean that the Scottish state would be failing in its duty to its citizens."

Joep Oomen of the European Coalition for Just and Effective Drug Policies (ENCOD) had another suggestion. "The only decent reaction to this kind of episode is to immediately open facilities where people can test their heroin and where they can use in safe conditions, supervised by people who can help if anything goes wrong," he said.

"Hopefully, in the longer term, because of these incidents, authorities will start to see the need for introducing heroin maintenance programs, not as a trial for a limited group of people, but as a permanent service for all those who cannot abstain from heroin for a longer period of time," he added.

Ultimately, said Oomen, prohibition is the problem. "Adulteration is a practice that belongs to the illegal market," he said. "It happens because the people who control the heroin market have no interest at all in the health of their customers."

Dr. Sharon Stancliff of the US Harm Reduction Coalition agreed with her colleagues' assessment of the Scottish government's response. "Telling people to stop is not useful information," she said. "Maybe some occasional users will have a glass of wine instead, but if people are sick and treatment is limited, telling people that heroin is bad for them isn't going to have much impact," she explained.

"At this point, the European harm reduction people should be getting the word out, and the medical people over there need to be on the alert," she added.

Stancliff said she had seen no sign of heroin contaminated with anthrax on this side of the Atlantic, but she was worried. "I hope the DEA is out there buying heroin to see what's in it," she said. "If there is any hint of it here, physicians should be alerted by the Centers for Disease Control as they were with levamisole-tainted cocaine."

If the anthrax-contaminated heroin is coming from Afghanistan, as most heroin consumed in Europe does, US heroin users may catch a break. Most heroin consumed here is of Mexican or Colombian provenance.

But on the other side of the Atlantic, adulterated heroin is killing drug users.

Feature: New York Post's Attack on "Heroin How-to" Harm Reduction Pamphlet Fails to Get It Dropped

Harm reduction in New York City came under attack last weekend when the tabloid New York Post ran an article titled Heroin for Dummies, excoriating the city for spending $32,000 for a 2007 harm reduction pamphlet that, among other things, gave injection drug users advice on how to reduce the harm of injecting. Since then, the story has been picked up by the New York Times and national media, including CNN and Fox News.

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uncomfortable, but the right thing to do
But while the assault on evidence-based harm reduction practices is worrisome, it also sparked a vigorous defense of the pamphlet from Mayor Michael Bloomberg and city health officials and has provided an opportunity to broaden public awareness of harm reduction. By Thursday, despite demands that they be pulled, Health Commissioner Thomas Farley had decided that the pamphlets will continue to be distributed.

The pamphlet, Take Charge, Take Care, was distributed by the city's Department of Health and Mental Hygiene and was aimed at injection drug users in the city. The harm reduction purpose behind it was to save lives and prevent overdoses and the spread of blood-borne disease. It counsels things like quitting, not sharing needles, and seeking treatment.

But also included in its advice were things like "Find the vein before you try to inject," "If you don't register [hit the vein], pull out and try again," and "Warm your body (jump up and down) to show your veins." Such common-sense harm reduction advice was like waving a red flag for Post and the drug warriors it interviewed.

"It's basically step-by- step instruction on how to inject a poison," said John Gilbride, head of the DEA's New York office. "It concerns me that the city would produce a how-to on using drugs," Gilbride said. "Heroin is extremely potent. You may only get the chance to use it once. To suggest there is a method of using that alleviates the dangers, that's very disturbing."

"It's sick," said City Council member Peter Vallone Jr. (D-Queens), chair of the council's public safety committee, who vowed to try to shut down distribution of the pamphlet. "This is a tremendous misuse of city funds, and I'm going to see what I can do to stop it. It sends a message to our youth: give it a try," he fumed.

"What we do not want to do is suggest that there's anything safe about shooting up narcotics," said Bridget Brennan, the city's special narcotics prosecutor. "No matter how many times you wash your hands or how clean the needle is, it's still poison that you're putting in your veins."

Only at the very end of the Post article was any supporter of harm reduction or the pamphlet given a say. "Our goal is to promote health and save lives with this information," explained Daliah Heller, assistant commissioner for the Bureau of Alcohol and Drug Use Prevention, Care and Treatment. "From a health perspective, there is a less harmful way to inject yourself."

The New York Times article the following day was less one-sided than the Post's hit piece, but still gave Vallone and other critics top billing. "You're spending taxpayer money and getting a how-to guide for first-time users," Vallone claimed.

The pamphlet was "absolutely not" a how-to manual, Dr. Adam Karpati, executive deputy commissioner for the health department's division of mental hygiene, told the Times. "Our primary message, as it is in all our initiatives, is to help people stop using drugs and to provide them with information on how to quit," Karpati said, adding that health officials recognized that quitting was not a realistic expectation for all drug users.

While Karpati was playing defense, harm reduction supporters went on the offensive. "The Health Department's booklet is solidly grounded in science and public health," said Ethan Nadelmann, executive director of the Drug Policy Alliance. "But the same cannot be said of the irresponsible comments by John Gilbride, Bridget Brennan, and Peter Vallone, Jr. These sorts of reckless statements by top level city and federal law enforcement agents need to be repudiated by their superiors in city and federal government."

On Monday, Mayor Bloomberg defended the pamphlet. "I would certainly not recommend to anyone that they use hard drugs or soft drugs," Bloomberg said. "But our health department does have an interest in if you're going to do certain things to get you to do it as healthily as you possibly can."

Now that the flap is behind them, two leading harm reductionists are assessing what it all means. "There was a political agenda at work with this," said Allan Clear, head of the Harm Reduction Coalition. "The District Attorney's Office fed this to the Post. This is a deliberate attack, and it follows on the footsteps of Rockefeller drug law reform, where DAs had some of their power stripped away. This was a red rag for foes to wave to provoke people, when the amount spent on the brochure is relatively small."

"This was not a book for people who have never injected," said Robert Heimer, professor at the Yale School of Public Health. "We know that people use opiates for around three years before they start injecting, and they don't do it because of a pamphlet, but because they are following their friends' example. This pamphlet was distributed at needle exchanges, STD clinics, drug treatment centers, and to people leaving Rikers Island. That's who the audience is, not people who have never injected."

Neither Clear nor Heimer thought much of the press coverage, although Clear was more charitable to the Times than Heimer. "The brochure has been deceptively portrayed consistently in all the articles," said Clear. "This is a manual aimed at people who are using injection drugs. The first thing it says is if you want help, call this number. If you compare the articles in the Post and the Times, the anti-drug user invective in the Post was just horrendous and demonstrated a very biased position to begin with," said Clear. "The conversation in the Times was much more pro-public health and sympathetic."

"The Times article was incredibly negative," said Heimer. "The first eight or ten paragraphs were all the opposition, and only after that do you get to the health department and why it's a common sense public health approach. When you have 'liberal media' like the Times and rightwing Murdoch papers like the Post both condemning you, you are under a lot of pressure to change."

When all is said and done, did the pamphlet flap turn out to be a boon or a bane for harm reduction? Again, the two men differed.

"When you get this on Fox News or CNN and people are talking about it, even though the initial effort was to discredit the brochure, it actually brought harm reduction to public consciousness in a good way," said Clear. "While we feel attacked, there has been a lot of positive response, and this has raised the profile of harm reduction and the need to educate drug users. The public reaction hasn't been that bad; in fact, it's been quite good."

"Any time there is negative press, it's not good for harm reduction," said Heimer. "It's still fragile here. In places like Holland, Britain, Canada, and Australia, harm reduction is one of the four pillars -- prevention, treatment, law enforcement, harm reduction -- but in this country, very little is done about prevention, there is not enough drug treatment because there is not enough emphasis on demand reduction, and we spend all our money on supply reduction, and we know how that has worked."

Feature: Busted for Handing Out Clean Needles -- The Mono Park 2 Fight Back in California's Central Valley

Hit hard by a double whammy of drought and economic slowdown, California's Central Valley has become a hotbed of methamphetamine and other injection drug use. Now, the dusty town of Modesto, in Stanislaus County, has become a focal point in the statewide and nationwide battle over how to help injection drug users. Last week, two volunteers at an unsanctioned needle exchange were in court in Modesto hoping to reach a plea bargain after they were arrested in April for handing out syringes. Now known as the Mono Park 2, they're looking at serious jail time for trying to save lives.

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mobile needle exchange/clinic site in nearby Fresno
The deal was supposed to be that Stanislaus County District Attorney Birgit Fladager would drop drug paraphernalia possession charges against exchange volunteers Kristy Tribuzio and Brian Robinson if they agreed to quit handing out needles until there was a legal program in place. But that didn't happen. Instead, at the last minute, the DA rejected the plea deal. Another hearing is set for November 9. If the DA and defense attorneys cannot reach agreement then, the case will go to trial.

The case has its genesis in longstanding efforts to win official approval for a needle exchange in Modesto. California law allows for needle exchanges, but only as a local option. The county board of supervisors must declare a health emergency in order for needle exchanges to operate legally.

In a 2008 report, Containing the Emerging Threat of Hepatitis through a Syringe Exchange Program (begins on page 22), the Stanislaus County Civil Grand Jury recommended the county authorize syringe exchanges and implement them either directly or through a community based contractor. The effort also had the support of county public health officials, including Public Health Department, the Advisory Board for Substance Abuse Programs, the Local AIDS Advisory Implementation Group, and the Hepatitis C Task Force, who cited a high incidence of Hepatitis C. They cited research indicating that needle exchanges reduced the spread of blood-borne diseases, brought injection drug users into contact with public health workers, and did not result in increases in drug use.

But despite the input from the public health community and the grand jury report, the Stanislaus County Board of Supervisors a year ago voted unanimously against allowing needle exchanges. In so doing, they heeded their own prejudices and those of law enforcement over science-based policies and the advice of the public health community.

County Sheriff Adam Christianson and DA Fladager both spoke out against needle exchanges, saying they would enable drug users to continue their addiction. Fladager said needle exchanges sent the wrong message to young people and encouraged them to think the county would take care of them if they become addicted.

"All of the challenges we are faced with in Stanislaus County, the gangs, methamphetamine, crimes, all have elements of drug addiction," Christianson said. "A syringe exchange program enables people to continue with their drug addiction."

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used syringes collected by exchange -- they might otherwise have been discarded in public places
Noting that Hep C was not a big issue for the county because most patients are covered by insurance, Supervisor Bill O'Brien also objected on bizarre moral grounds. "Then there's the human issue. Giving a drug user a clean needle is not the best thing for him. Illegal drug use has a risk, and making it safer promotes it," he said.

Supervisor Jim DeMartini thanked the grand jury for the report, but then dismissively added, "Like many well-intentioned programs that don't work out, this will never work out and deliver the benefits promised."

Too bad the sheriff, the DA, and the county board don't agree with the nation's drug czar. "Needle exchange programs have been proven to reduce the transmission of blood-borne diseases," Gil Kerlikowske told Congress during confirmation hearings earlier this year. "A number of studies conducted in the US have shown needle exchange programs do not increase drug use. I understand that research has shown these programs, when implemented in the context of a comprehensive program that offers other services such as referral to counseling, healthcare, drug treatment, HIV/AIDS prevention, counseling and testing, are effective at connecting addicted users to drug treatment."

Given the knowledge base about the effectiveness of exchanges and the evident human need for them in Modesto, needle exchange advocates were not content to simply roll over and die. Instead, they created an unauthorized needle exchange in the city's Mono Park, also known as needle park by residents because of the used needles littering the ground there. The program was publicized and went along on a low-level basis without a hitch until April, when, after an elaborate undercover sting, police swooped down and arrested the exchange volunteers.

Kristi Tribuzio just happened to be volunteering with the needle exchange the day the bust went down. Now, she's one of the defendants. "There was a direct need for this, and when I found out there was an existing exchange -- I saw a flyer on a telephone pole -- I asked how is this happening?" she said. "I got involved; I was just going out there for the people. An undercover cop came up and did an exchange, and then, a little later eight to 10 undercover officers drove up with a drug dog and arrested us. It was pretty harsh and crazy," she recalled.

"Looking back, Brian and I think it was maybe naive of us to just go out there and do something that was helping people in line with other syringe exchange programs," said Tribuzio. "We didn't understand what the consequences could be."

Now, she and Robinson face up to a year in jail for violating the paraphernalia law. For Tribuzio, there were other consequences, including the loss of her contract position with the Stanislaus County drug and alcohol education and prevention program. "I was laid off two days after I was arrested. Because I was a contract worker, they didn't need a reason to fire me, and no official reason was given. Ironically, my employer supports needle exchange," she said. "Maybe that's why they laid me off instead of firing me for cause. Now, at least, I can get unemployment."

Tribuzio had previously worked as a substitute teacher, but she can't do that now, either. "I'm getting an MA in education, and I have a teaching credential, but my credential is now suspended," she said. "Imagine, a teacher in San Francisco could be doing just what I did, and there would be no problem."

That's because needle exchanges have been authorized by the San Francisco County Board of Supervisors, just as they have in most large California cities. But in more conservative locales, like the Central Valley, the fight is more difficult, and therein lies the problem -- and the solution -- said one prominent harm reductionist.

"What we need is to get legislation authorizing syringe exchanges on a statewide level rather than our current system, which requires that they be authorized by local authorities," said Hilary McQuie, Oakland-based Western director of the Harm Reduction Coalition. "Requiring local authorization means we have to deal with 54 jurisdictions instead of just one, and the politics makes it really difficult in conservative places like Fresno or Modesto. It will be really difficult to get syringe exchange approved in Modesto without a statewide mandate," she said.

Short of that, needle exchange advocates need to carefully lay the groundwork beforehand, she said. In that respect, the Modesto needle exchange perhaps suffered from political naivete. "The effort with the grand jury in Modesto was done in good faith, but the grand jury finding required a response from the Board of Supervisors within three months," she noted. "They hadn't really lined up their support with the Board, and the Board ended up voting against it. That was problematic."

While personally difficult for Tribuzio and Robinson, the battle over needle exchanges in Modesto has moved the issue forward locally and stirred support from around the country and the world. A Mono Park 2 Defense Committee has formed to back them. At last week's hearing, more than a dozen supporters were present in court, and the pair had letters of support from some 35 public health and harm reduction organizations here and abroad.

"We've gotten a ton of support from the harm reduction community," said Tribuzio. "This whole thing has been stressful and overwhelming for us, but they've given us a wealth of training, knowledge, and support, more than we ever expected. We've gotten support from people in other exchanges, and letters of support from around the world. We've also been building alliances with people in the community. Things in the Central Valley are crazy, and we can't turn our heads away in the face of disease. Now, at least, people are paying attention."

While Robinson and Tribuzio wait for their legal problems to be resolved, they continue to work with at-risk communities. "After the bust, we started Off The Streets, and that does everything except for needle exchange," said Tribuzio. "We're doing needs assessments, trying to get our fingers on the pulse of the community, trying to help where we can."

For McQuie, the trials and tribulations of the Mono Park 2 are, sadly, par for the course. "This is how most of the programs got started, doing them illegally, so they're in good company," she said.

Asia: Drug Users Form Regional Drug User Organization

In a meeting in Bangkok last weekend, more than two dozen drug users from nine different countries came together to put the finishing touches on the creation of a new drug user advocacy organization, the Asian Network of People who Use Drugs (ANPUD). The Bangkok meeting was the culmination of a two-year process began at a meeting of the International Congress on AIDS in Asia and the Pacific in Colombo, Sri Lanka, in 2007, and resulted in creating a constitution and selecting a steering committee for the new group. ANPUD adopts the principles of MIPUD (Meaningful Involvement of People who Use Drugs), and in doing so, aligns itself with other drug user advocacy groups, including the International Network of People who Use Drugs (INPUD), of which ANPUD is an independent affiliate, the Australian Injection and Illicit Drug Users League (AIVL),the Vancouver Area Network of Drug Users, and the Nothing About Us Without Us movement. ANPUD currently has more than 150 members and sees its mission to advocate for the rights of drug users and communities before national governments and the international community. There is plenty to do. Asia has the largest number of drug users in the world, but is, for the most part, woefully retrograde on drug policy issues. Not only do drug users face harsh criminal sanctions—up to and including the death penalty—but Asian has the lowest coverage of harm reduction services in the world. Access to harm reduction programs, such as needle exchanges and opioid maintenance therapy, is extremely limited. "People who use drugs are stigmatized, criminalized and abused in every country in Asia," said Jimmy Dorabjee, a key figure in the formation of ANPUD. "Our human rights are violated and we have little in the way of health services to stay alive. If governments do not see people who use drugs, hear us and talk to us, they will continue to ignore us." The Director of the UNAIDS Regional Support Team, Dr. Prasada Rao, spoke of the urgent need to engage with drug user networks and offered his support to ANPUD, saying that "For UNAIDS, HIV prevention among drug users is a key priority at the global level," said Dr. Prasada Rao, director of the UNAIDS Regional Support Team. "I am very pleased today to be here to see ANPUD being shaped into an organization that will play a key role in Asia's HIV response. It is critical that we are able to more effectively involve the voices of Asian people who use drugs in the scaling up of HIV prevention services across Asia." "When I go back home, I am now responsible for sharing the experiences with the 250 or so drug users who are actively advocating for better services at the national level," said Nepalese drug user and newly elected steering committee member Ekta Thapa Mahat. "It will be a great way for us to work together and help build the capacity of people who use drugs in Asia." "The results of the meeting exceeded my expectations," said Ele Morrison, program manager for AVIL's Regional Partnership Project. "The participants set ambitious goals for themselves and they have achieved a lot in just two days to set up this new organization. The building blocks for genuine ownership by people who use drugs is definitely there." While the meetings leading to the formation were organized and managed by drug users, the process received financial support from the World Health Organization, the UNAIDS Regional Task Force, and AIVL.
Location: 
Bangkok
Thailand

Feature: Federal Needle Exchange Funding Ban Battle Continues

Years of effort by harm reductionists, public health authorities, HIV/AIDS researchers and activists, and drug law reformers to undo the more than 20-year-old ban on federal funding for needle exchange programs (NEPs) may come to fruition this year, but there are significant obstacles to overcome. Still, advocates of the reform are cautiously optimistic.

Since 1988, the US government has prevented local and state public health authorities from using federal funds for NEPs, which studies have shown to be effective in reducing HIV infection rates among injection drug users (IDUs) and their sexual partners, promoting public health and safety by taking syringes off the streets, and protecting law enforcement personnel from injuries. NEPS have been endorsed by the World Health Organization, the American Medical Association, Centers for Disease Control and Prevention Director Thomas Frieden, and former Surgeons General Everett Koop and David Satcher, among many others.


Chicago map demonstrating the impact of the
1000-foot rule -- click for larger copies and more
maps of Chicago and San Francisco (courtesy
Dr.Russell Barbour, Center for Interdisciplinary
Research on AIDS, Yale School of Medicine)

Injection drug use accounts for up to 16% of the 56,000 new HIV infections in the US every year -- or nearly 9,000 people. IDUs represent 20% of the more than 1 million people living with HIV/AIDS in the US and the majority of the 3.2 million Americans living with hepatitis C infection.

Still, those numbers could have been higher. In a 2008 study, the CDC concluded that the incidence of HIV among injection drug users had decreased by 80% in the past 20 years, in part due to needle exchange programs. There are today an estimated 185 NEPs operating in 36 states, the District of Columbia, and Puerto Rico. But they rely on local or private funds, and many of them are failing to meet demand because of lack of funding. While the CDC says that its public health policy goal is 100% needle exchange, current estimates are that only 3.2% of needles used by drug users in urban areas are exchanged for clean ones.

The federal funding ban was first removed in a July 10 vote of the House Subcommittee on Labor, Health and Human Services, Education, and Related Agencies. A week later, the full Appropriations Committee approved the bill after voting down an amendment proposed by US Rep. Chet Edwards (D-TX) that would have reinstated the funding ban.

But the Appropriations Committee did approve an amendment dictating that federally funded NEPs could not operate "within 1,000 feet of a public or private day care center, elementary school, vocational school, secondary school, college, junior college, or university, or any public swimming pool, park, playground, video arcade, or youth center, or an event sponsored by any such entity."

A floor amendment by Rep. Mark Souder (R-IN) to reinstate the funding ban also was defeated, clearing the way for repeal of the ban to pass the House. But the thousand-foot language remains in the appropriations bill approved by the House, and it's extremely objectionable to reform advocates. The Senate committee working on the issue did not include ending the funding ban, but reform advocates are pinning their hopes on both ending the ban and killing the thousand-foot restriction on the end-game House-Senate appropriations conference committee.

"The Senate has taken up their version of the bill in committee, but hasn't had a full vote," explained Daniel Raymond, policy director for the Harm Reduction Coalition. "At the committee level, the Senate chose not to take any action on the ban. At this point, there is a conflict between the House and the Senate." HRC is lobbying the Senate to repeal the ban, without the restrictions.

"We commend the full House for recognizing that NEPs are essential, effective tools that work in our fight against HIV and hepatitis transmission," said Kevin Robert Frost, chief executive of the Foundation for AIDS Research. "And while the compromise in the bill isn't perfect, we are hopeful that a final bill will reach President Obama's desk without limitations."

"We urge Congress to recognize both the benefit and cost-savings of syringe exchange programs, and the research that NEPs do not have detrimental impact on communities," said Marjorie Hill of Gay Men's Health Crisis, which has just released yet another study demonstrating NEPs' effectiveness in decreasing the transmission of blood-borne diseases. "For too long, we have allowed ideology to drive public health policy. It is time to remove the federal funds ban for syringe exchange and remove the harmful 1,000 feet restriction," added Hill.

"The House bill, as it stands, still puts ideology before science by limiting how federal funds can be used for NEPs," Frost said. "But we have time to fix the legislation, and I'm hopeful that the full US Congress will realize the importance of allowing local elected and public health officials to make their own decisions about how to address their HIV and hepatitis epidemics."

"I believe that the president, the Senate, and the House all want to do the right thing and they're trying to figure out how to do it," said Bill McColl of AIDS Action. "If they follow their own rhetoric about science- and evidence-based HIV/AIDS prevention policy, then they will remove the thousand-foot restriction," he said.

"The thousand-foot provision is a backdoor means of reinstating the funding ban," McColl continued. "There is almost no urban environment in which it would allow needle exchanges to operate. There are no currently existing needle exchanges that would be able to get federal funding, so it just doesn't make sense to change the policy that way. Drug policy groups have gone and literally shown Congress maps of what would be excluded. They've got letters from mayors and police saying this is not a workable provision. Again, Congress and the president know what the science is."

In addition to eliminating federally-funded needle exchanges in vast swathes of the urban landscape, the thousand-foot rule would have other insidious effects, said McColl. "Having that rule would have undesirable side effects, in that it would separate needle exchange from other public health services. Our AIDS program does testing in areas with lots of drug use -- that's where we need to be testing, and that's where we want the population to have clean syringes. With federal funding available and with the thousand-foot rule, prevention services will be driven away from needle exchanges."

Alice Bell, prevention project coordinator for Prevention Point Pittsburgh, already lives with geographical restrictions. "We have a local regulation that specifies 1,500 feet from schools only, not all the other restrictions in the current language of the federal bill. We have to move our main needle exchange site because the building we're in is being sold, and we're having trouble finding a good place. Any federal restrictions would make it even tougher," she said.

Bell wants the federal funding ban ended, but worries that the thousand-foot rule would put a crimp in her efforts. "We still want it. We need the federal funding. Our program is expanding, but we can't really expand our exchange service because we don't have money for needles. The toughest thing is always getting money for needles. Ending the federal funding ban would make a huge difference to us."

Federal funding becomes even more significant when coupled with economic hard times and budget problems at the state and local level, Bell noted. "We're mostly funded through foundations and private donations, and we've begun getting some state and county money for overdose prevention and HIV prevention, but the needle exchange -- the core of what we do -- is the toughest to get funded."

"The Senate will most likely go along with the House in conference committee," said Drug Policy Alliance director of national affairs Bill Piper. "They will probably take a bunch of appropriations bills and put them in a massive omnibus spending bill. It is far from clear that there will be a ban in what comes out of the Congress."

But the thousand-foot rule has to go, he said. "A lot of groups have been lobbying really hard on the thousand-foot issue," Piper noted. "It would be an effective ban is many cities. Here in DC, for example, the only place you could do a needle exchange program would be down at the docks on the Potomac. The strategy is to convince the conference committee to either take that out or come up with something better."

Advocates are lobbying hard right now, said the Harm Reduction Coalition's Raymond. "Right now, we're doing a push to make sure the Senate is educated about the issue and ask the leadership to get on board with House's action to address the ban," he said. "The House version has the thousand-foot restriction, so we're also making the arguments about why that's not workable and needs to be redone. We've been circulating maps showing its impact to House members who are focused on the issue. This restriction goes far beyond any reasonable desire to balance public health with other interests. When that provision was thrown in at the last minute, its effects hadn't really been thought out," he argued.

"We keep up the work in reaching out to Congress on both House and Senate side," said Raymond, "and we're also asking the White House to show some leadership and urge the Senate to address the federal ban. We don't want this issue to get lost in the shuffle, we're calling on everyone in the community to make our voices heard and reaching out to our elected officials."

It may take awhile to get settled, said Piper. "The entire appropriations process is messed up, and a lot of will depend on if, when, and how the Senate deals with health care," he explained. "Supposedly, they will get the appropriations bills done by the end of October, but I think that's a fantasy. Last year, they didn't even do this year's appropriations bills until March."

Still, AIDS Action's McColl maintains a positive outlook. "I think the members who will be called on to vote on this understand the issues," he said. "I have a pretty good feeling about this. I'm hopeful this is the year."

Harm Reduction: Pennsylvania Allows Syringe Sales Without Prescription, Effective Immediately

Responding to years of agitation by harm reductionists and public health advocates, the Pennsylvania Board of Pharmacy Saturday published new regulations that will allow pharmacies to sell syringes without a prescription. The change goes into effect immediately. The move was lauded by activists as a significant public health victory in the battle against the spread of HIV/AIDS and Hepatitis C via injection drug use.

http://stopthedrugwar.org/files/nline.gif
popular syringe exchange logo
Under previous regulations, pharmacies could sell syringes only to people who obtained a doctor's prescription. The new regulations carry no limit on the number of syringes that can be purchased at a time, nor do they have age limits.

"This change is particularly important in Pennsylvania because we have only two locations -- Pittsburgh and Philadelphia -- in which legally authorized syringe exchange programs operate," said David Webber, an attorney for the AIDS Law Project of Pennsylvania. "These two programs alone are simply not adequate to address this problem across the entire state, but syringe exchange programs continue to be crucial in providing sterile syringes as well as access to drug treatment and health care for injection drug users."

"This is a chance for every pharmacy to become part of HIV prevention in Pennsylvania," said Scott Burris, professor at Temple University's School of Law and a national authority on syringe regulation and HIV prevention. "The pharmacy board has taken an important step forward for evidence-based policy."

It didn't come swiftly or easily. Activist organizations including the Pennsylvania Aids Law Project, Prevention Point Pittsburgh, Prevention Point Philadelphia, as well as legislators, HIV workers, and others had lobbied for the change for a decade. An article in the Lancaster Intelligencer Journal cited several efforts:

  • In 2002, a group called the Pennsylvania Coalition for Responsible Syringe Policy asked the Pharmacy Board to consider deregulation.
  • In 2005, another group called Pennsylvanians for the Deregulation of Syringe Sales filed a formal petition to the Board, and met with legislators and officials in the Rendell Administration.
  • In 2007, the the Pennsylvania Pharmacists Association endorsed syringe deregulation and asked the Pharmacy Board to move swiftly on it.

Robert Field, organizer of Pennsylvanians for the Deregulation of Syringe Sales and co-chair of the Lancaster-based Common Sense for Drug Policy, told the Intelligencer Journal he looked at syringe deregulation after efforts to start a syringe exchange program in Reading met with opposition. The board responded in August 2007, proposing new regulations allowing for over-the-counter syringe sales and opening them up for public comment. Thanks to concerns expressed by harm reduction and public health groups during the comment period, the board removed age and quantity restrictions.

The board heard a number of concerns from the Pennsylvania Medical Society that the rule change would increase drug use. But research won the day. "Studies indicate that making syringes available will reduce the spread of HIV and will not lead to an increase of illicit drug use," said Field.

The board also rejected record-keeping requirements requested by the House Professional Licensure Committee, saying it "does not believe that maintaining a record and requiring individuals to provide a name or other identifying information would advance the public health and safety."

Now the number of states that do not allow syringe sales without a prescription is down to two: Delaware and New Jersey.

Harm Reduction: Pennsylvania Allows Syringe Sales Without Prescription, Effective Immediately

Responding to years of agitation by harm reductionists and public health advocates, the Pennsylvania Board of Pharmacy Saturday published new regulations that will allow pharmacies to sell syringes without a prescription. The change goes into effect immediately. The move was lauded by activists as a significant public health victory in the battle against the spread of HIV/AIDS and Hepatitis C via injection drug use. Under previous regulations, pharmacies could sell syringes only to people who obtained a doctor’s prescription. The new regulations carry no limit on the number of syringes that can be purchased at a time, nor do they have age limits. “This change is particularly important in Pennsylvania because we have only two locations--Pittsburgh and Philadelphia--in which legally authorized syringe exchange programs operate,” said David Webber, an attorney for the AIDS Law Project of Pennsylvania. “These two programs alone are simply not adequate to address this problem across the entire state, but syringe exchange programs continue to be crucial in providing sterile syringes as well as access to drug treatment and health care for injection drug users.” “This is a chance for every pharmacy to become part of HIV prevention in Pennsylvania,” said Scott Burris, professor at Temple University’s School of Law and a national authority on syringe regulation and HIV prevention. “The pharmacy board has taken an important step forward for evidence-based policy.” It didn’t come swiftly or easily. Activist organizations including the Pennsylvania Aids Law Project, Prevention Point Pittsburgh, Prevention Point Philadelphia, as well as legislators, HIV workers, and others had lobbied for the change for a decade. In August 2007, the pharmacy board proposed new regulations allowing for over-the-counter syringe sales and opened them up for public comment. Thanks to concerns expressed by harm reduction and public health groups during the comment period, the board removed age and quantity restrictions. The board rejected record-keeping requirements requested by the House Professional Licensure Committee, saying it “does not believe that maintaining a record and requiring individuals to provide a name or other identifying information would advance the public health and safety.” Similarly, it rejected a number of concerns from the Pennsylvania Medical Society that the rule change would increase drug use. The board’s action reflected well-established scientific evidence that access to clean syringes is a critical component of stemming the spread of blood-borne diseases such as HIV and Hep C among injection drug users. Now the number of states that do not allow syringe sales without a prescription is down to two: Delaware and New Jersey.
Location: 
PA
United States

Harm Reduction: Funds Begin to Flow to DC Needle Exchange Programs

Eight months after Congress voted to end a decade-long ban on the use of federal funds for needle exchange programs (NEPs) in the District of Columbia, money is starting to flow to the programs in the city with the nation's highest rate of HIV. District officials had announced almost immediately after the congressional vote that they would fund NEPs in an effort to control the spread of the disease among injection drug users.

http://stopthedrugwar.org/files/preventionworksatwork.jpg
PreventionWorks! at work (screen shot from nytimes.com '''slide show,'' June '07)
Now, according to the Washington Times, funding is finally reaching the city's NEPs. The city will spend $700,000 a year on NEPs, with the city's largest program, PreventionWorks!, getting $300,000 a year.

According to a DC HIV/AIDS Administration 2007 report, injection drug use is the second most common mode of acquiring the HIV virus after unprotected sex, and the District has some 10,000 injection drug users.

DC NEP advocates have long argued that the federal funding ban left them starved for funds and unable to adequately address the injection drug using population. PreventionWorks!, for example, has had to scrape by on private contributions, limiting the work it has been able to do.

The need is obvious and so is the response, Ken Vail, the group's executive director, told the Times. "If you want to reduce the spread of HIV... you put more syringes out there," he said.

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