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Opiate Maintenance: Prescribing Heroin to Hard-Core Addicts Keeps Them Off Street Smack, British Study Finds

In research findings reported in The Lancet, scientists monitoring the Randomized Injectable Opiate Treatment Trial (RIOTT) reported that allowing addicts who have failed to get off heroin to use injectable "medical grade" heroin resulted in lower levels of street heroin use than in addicts given either oral or injectable methadone. The research was done by Professor John Strang and colleagues from the National Addiction Center's Institute of Psychiatry at King's College in London.

Up to 10% of heroin addicts fail to respond to conventional treatments, for reasons that are unclear. In recent years, scientific evidence suggesting that providing medicinal heroin, known as diamorphine in the United Kingdom, under supervision is an effective treatment for chronic heroin addiction, has only increased. This study adds to the mounting evidence.

The RIOTT study chose as subjects chronic addicts who were receiving oral maintenance doses, typically of methadone, but were continuing to regularly inject street heroin. Subjects were provided with oral methadone, injectable methadone, or injectable heroin over a half-year period. At the end of the study, 80% of the subjects remained in treatment, with the highest figure for those using heroin (88%), followed by injectable methadone (81%) and oral methadone (69%). Among subjects who had 50% or more negative samples for street heroin -- the authors' measure of measurable improvement -- 66% of medicinal heroin users avoided street smack, while only 30% of injectable methadone users did and only 19% of oral methadone users did.

"We have shown that treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone," the authors said in a press release announcing the findings. "Furthermore, this difference was evident within the first six weeks of treatment."

Noting that the UK government's 2008 Drug Strategy had called for rolling out prescription heroin and methadone to clients who don't respond to other forms of treatment, contingent on the results of the RIOTT study, the authors said the results were in and it was time to act. "In the past 15 years, six randomized trials have all reported benefits from treatment with injectable heroin compared with oral methadone. Supervised injectable heroin should now be provided, with close monitoring, for carefully selected chronic heroin addicts in the UK," they concluded.

"Our scientific understanding about how to treat people with severe heroin addiction has taken an important step forward," said Professor Strang. "The RIOTT study shows that previously unresponsive patients can achieve major reductions in their use of street heroin and, impressively, these outcomes were seen within six weeks. Our work offers government robust evidence to support the expansion of this treatment, so that more patients can benefit."

You can watch Professor Strang discuss the findings here.

Feature: Schwarzenegger Trying to Gut California Methadone Funding in Budget Move

With California facing a $19 billion budget deficit, Gov. Arnold Schwarzenegger (R) last month proposed saving the state $53 million by cutting off Medi-Cal funding for methadone maintenance for most heroin addicts. That would cause the loss of more than $60 million in matching federal funds. The move was fiercely resisted by methadone advocates -- including a former drug czar -- and public policy analysts, and the proposal was defeated last week in committee votes in the state Senate and Assembly.

But California gives the governor the power to veto individual budget items, so advocates are not resting yet. Instead they are reaching out to the administration in hopes they can enlighten it and persuade the budget axe-wielding Schwarzenegger to aim elsewhere.

Schwarzenegger isn't the first top-tier elected official to go after methadone maintenance. Back in 1999, then New York City Mayor Rudy Giuliani vowed to wean all of the city's methadone patients off it in three months. While Giuliani acted for ideological rather than budgetary reasons -- he said he wanted "drug freedom," not drug dependence -- the pugnacious mayor later changed his tune, admitting the idea was "maybe somewhat unrealistic."

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superheroes for harm reduction: ''Methadone Man'' public awareness campaign during last February's Olympics in Vancouver. You're needed everywhere, Methadone Man.
Currently, nearly 150 methadone clinics provide the heroin substitute to some 35,000 addicts, 55% of whom are on Medi-Cal. Advocates and treatment providers said that clinics would be forced to close if the proposal passed, affecting not only the Medi-Cal patients, but also patients who paid out of their own pockets or through private insurance to be able to get maintenance methadone.

"Methadone isn't a cure," said Roxanne Baker, president of the National Alliance of Methadone Advocates (NAMA), "but much like thyroid medication, as long as you keep taking it, it keeps your disease in check, and opiate addiction is a disease. When you mess with your brain with painkillers, it then doesn't produce the endorphins it should. It's not a matter of will power, it's a disease. You need something to replace those endorphins, whether its methadone, suboxone, or even prescription heroin, although I doubt we'll ever see that here."

Enacting the proposed cuts would be "a disaster," said Baker. "There would be no methadone programs left. More than half the patients statewide are on drug MediCal, and they wouldn't even have a place to go. A lot of these people have their lives in order. This is somebody's brother, somebody's aunt, somebody's mom. Please don't take this from us."

Last week, Clinton-era drug czar Gen. Barry McCaffrey flew into the state to hold a press conference denouncing the cut. "Dumping tens of thousands of opiate addicts back on the street would be an immediate disaster to law enforcement, and to the families of people who have become stable, functioning adults" thanks to methadone, said McCaffrey, who has a consulting firm and serves on the board of directors of an organization that treats chemical dependency.

Legislators were listening, not only to McCaffrey, but to the methadone treatment community. A Senate Budget Committee hearing last week proved tough going for Schwarzenegger's representatives.

"This measure would eliminate the drug MediCal program with the exception of the perinatal and youth funding," said John Wardlaw from the state Department of Finance. "This is not an easy reduction in any way. We are at the point where we are making very difficult reductions."

Committee Chair Denise Moreno Ducheny (D-San Diego) wasn't buying it. "How much federal funding are you giving up?" she asked.

"Sixty-six million dollars," Wardlaw said.

"We save $53 million and lose $66 million?" asked Ducheny.

"That is correct, ma'am."

Ducheny just stared at him for a few uncomfortable moments before moving on to the next witness.

"There would be cost shifts in the area of corrections and child welfare services," Greg Tallivant of the legislative analysts' office told the solons. "The day the clinic closes, those people have to do something. If they can't make it to the next methadone clinic, heroin would be the next choice. You would see people arrested. You would see prison costs and child welfare costs go up."

Assemblyman Mark Leno (D-San Francisco) was visibly irritated by the proposal. "There is a complete lack of interest in any cost-benefit analysis here," he said. "This is reckless and cavalier. It doesn't really make much sense. We have 171,000 people addicted to drugs. This will increase our crime rate; it's a recipe for disaster on our streets. Does the governor have no interest in this or does he not believe that this will impact the safety of our children and communities? We've already zero-funded the base Proposition 36 program. The outcome of this is to have drug offenders with no jail and no treatment."

"This is really a short-sighted proposal that shifts costs from funding treatment to funding law enforcement, jails, and prisons," said Jason Kletter, a member of the Bay Area Addiction Research Team (BAART), which is in turn a member of California Opioid Maintenance Providers (COMP), a nonprofit organization representing opioid maintenance treatment centers. "It is a public safety issue, to say nothing of the humanitarian crisis it would provoke," he said.

"We think if this happened many clinics would close, and the folks who lose access to care would likely relapse and cost the system much, much more in a short time," said Kletter. "We see relapse rates of 80% within a year when clinics close, so it wouldn't even be like we'd be kicking the can three or four years down the road."

"This would have the biggest impact on programs that have a high percentage of Medi-Cal beneficiaries in treatment and would be unable to stay open because more than half their patients, and thus, their revenues, are gone," said Kletter. "You would have a fundamental dismantling of the system."

The cost incurred would be staggering, Kletter said."If 80% relapse in same year, we know that the state will incur $700 million to $1 billion in new costs in the criminal justice system," he said, citing a study from the 1990s that found each dollar invested in treatment produced a seven-dollar return. "The state wants to save $53 million by eliminating drug Medi-Cal and will also turn away more than $60 million in matching funds. That's $115 total program cost. A seven-to-one return on that is close to a billion dollars. "With 80% relapse, we could end up seeing $700 million in new criminal justice and prison costs."

"It's a terrible proposal," said Glenn Backes, a Sacramento-based public policy analyst who works with the Drug Policy Alliance at the Capitol. "California Democrats in both houses have said so. The Senate Republicans didn't do a cost-benefit analysis; they just said we can't afford to give out subsidized health care."

But in reality, the situation is even worse, said Backes. "They've killed Proposition 36 funding, drug courts are being slashed. According to the governor's finance director, that's 171,000 patients. The cost-benefit for this is worse than nil. If only one out of a thousand relapses and goes to prison, you've already lost money because prison is so much more expensive than treatment. If only one out of a thousand gets Hep C, the taxpayer loses. If only one out of a thousand gets HIV, the taxpayer loses."

It's easy to lose the human side in all the numbers, Backes said. "If only one out of a thousand ODs and dies, that's 170 California families who have lost a loved one."

And the battle continues. "While both the Senate and the Assembly budget committees have rejected the governor's proposal, in California, the governor has a line item veto," said Kletter. "We are continuing to try to work with the administration to explain the impact of this kind of proposal and get them to understand it is a public safety and cost-shifting issue. We haven't had any direct meeting with them yet, but that's next on our agenda. We want to educate them about them dire consequences of this sort of action."

Even if advocates many to salvage the drug Medi-Cal program, they would be well-advised to be searching for alternative funding sources, and how better than to take money from the drug war? Tough times call for creative solutions, and Backes has one: Use federal Byrne Justice Assistance Grants to fund treatment instead of drug task forces. Every dollar funding more drug war arrests costs $10 additional in spending for courts and prisons, he said.

"Historically, Byrne grant funds have been given to task forces to increase arrests," Backes noted. "The Drug Policy Alliance position is that Byrne funds would be better spent on almost anything other than doing low-level drug sweeps. We would rather see that money go into treatment for people in the system."

Europe: Scottish Attitudes toward Drugs, Drug Users Harsh and Getting Harsher, Annual Poll Finds

Scottish public opinion is taking a harder line toward drug use and drug users, according to the Scottish Social Attitudes Survey 2009. Support for marijuana legalization has declined by half since 2001, while attitudes toward heroin users are harsh, and support for harsh punishments is stronger than support for harm reduction measures.

The poll comes after several years of a full-blown Reefer Madness epidemic in the United Kingdom press, where sensational assertions that "cannabis causes psychosis" have gained considerably more traction than they have in the US. It also comes as Scotland confronts an intractable, seemingly permanent, population of problem heroin users and increasing calls from Conservatives to treat them more harshly.

Throughout the 1980s and 1990s, support for marijuana legalization rose in Scotland, as if did throughout the UK, reaching 37% by 2001. Last year, it was down to 24%. The decline was especially dramatic among young people, with 62% of 18-to-24-year-olds supporting legalization in 2001 and only 24% last year.

Support was down even among people who have used marijuana. In 2001, 70% supported legalization; now only 47% do. Similarly, attitudes toward pot possession also hardened among the Scots public. In 2001, 51% agreed that people should not be prosecuted for possessing small amounts for personal use. In 2009, this figure fell to just 34%.

Scots don't have much use for heroin users, either. Nearly half (45%) agreed that addicts "have only themselves to blame," while just 27% disagreed. On the obverse, only 29% agreed that most heroin users "come from difficult backgrounds," while 53% disagreed. People who are generally more liberal in their values, people who have friends or family members who have used drugs, and graduates were all more likely to have sympathetic views toward heroin users.

Fewer than half (47%) would be comfortable working around someone who had used heroin in the past, while one in five would be uncomfortable doing so. Similarly, just 26% said they would be comfortable with someone in treatment for heroin living near them, while 49% said they would not be. Only 16% think heroin use should be decriminalized.

When it comes to policy toward heroin use, Scots were split: 32% wanted tougher penalties, 32% wanted "more help for people who want to stop using heroin," and 28% wanted more drug education. And four out of five (80%) agreed that "the only real way of helping drug addicts is to get them to stop using drugs altogether."

Those tough attitudes are reflected in declining support for needle exchanges, the survey's sole measure of support for harm reduction approaches. In 2001, 62% supported needle exchanges; now only 50% do.

It looks like Scottish harm reductionists and drug reformers have their work cut out for them.

Feature: Obama's First National Drug Strategy -- The Good, the Bad, and the Ugly

A leaked draft of the overdue 2010 National Drug Strategy was published by Newsweek over the weekend, and it reveals some positive shifts away from Bush-era drug policy paradigms and toward more progressive and pragmatic approaches. But there is a lot of continuity as well, and despite the Obama administration's rhetorical shift away from the "war on drugs," the drug war juggernaut is still rolling along.

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sign of the leaker?
That doesn't quite jibe with Office of National Drug Control Policy (ONDCP -- the drug czar's office) director Gil Kerlikowske's words when he announced in April 2009 that the phrase "war on drugs" was no longer in favor. "Regardless of how you try to explain to people it's a 'war on drugs' or a 'war on a product,' people see a war as a war on them. We're not at war with people in this country."

The leak was reported by long-time Washington insider and Newsweek columnist Michael Isikoff, who mentioned it almost off-handedly in a piece asserting "The White House Drug Czar's Diminished Status." Isikoff asserted in the piece that the unveiling of the strategy had been delayed because Kerlikowske didn't have the clout to get President Obama to schedule a joint appearance to release it. His office had been downgraded from cabinet level, Isikoff noted.

That sparked an angry retort from UCLA professor Mark Kleiman, a burr under the saddle to prohibitionists and anti-prohibitionists alike for his heterodox views on drug policy. In a blog post, Kleiman seemed personally offended at the leak, twice referring to the leaker as "a jerk," defending the new drug strategy as innovative if bound by interagency politics, and deriding Isikoff's article as "gossipy."

Kleiman also suggested strongly that the leaker was none other than former John Walters on the basis of an editing mark on the document that had his name on it. But Walters has not confirmed that, and others have point out it could have been a current staffer who is using the same computer Walters used while in office.

On the plus side, the draft strategy embraces some harm reduction programs, such as needle exchanges and the use of naloxone to prevent overdoses, although without ever uttering the words "harm reduction." There is also a renewed emphasis on prevention and treatment, with slight spending increases. But again reality fails to live up to rhetoric, with overall federal drug control spending maintaining the long-lived 2:1 ration in spending for law enforcement, eradication, and interdiction versus that for treatment and prevention.

The strategy also promotes alternatives to incarceration, such drug courts, community courts and the like and for the first time hints that it recognizes the harms that can be caused by the punitive approach to drug policy. And it explicitly calls for reform of the sentencing disparity for crack and powder cocaine offenses.

It sets a number of measurable goals related to reducing drug use. By 2015, ONDCP vows to cut last month drug use by young adults by 10% and cut last month use by teens, lifetime use by 8th graders, and the number of chronic drug users by 15%.

The 2010 goals of a 15% reduction reflect diminishing expectations after years of more ambitious drug use reduction goals followed by the drug policy establishment's inability to achieve them. That could inoculate the Obama administration from the kind of criticism faced by the Clinton administration back in the 1990s when it did set much more ambitious goals.

The Clinton administration's 1998 National Drug Control Strategy called for a "ten-year conceptual framework to reduce drug use and drug availability by 50%." That didn't happen. That strategy put the number of drug users at 13.5 million, but instead of decreasing, according to the 2008 National Household Survey on Drug Abuse and Health, by 2007 the number of drug users was at 20.1 million.

While Clinton took criticism from Republicans that his goals were not ambitious enough -- Newt Gingrich said we should just wipe out drugs -- the Bush administration set similar goals, and achieved similarly modest results. The Bush administration's 2002 National Drug Control Strategy sought a 25% reduction in drug use by both teenagers and adults within five years. While teen drug use declined from 11.6% in 2002 to 9.3% in 2007, then drug czar Walters missed his goal. He did less well with adult use almost unchanged, at 6.3% in 2000 and 5.9% in 2007.

The draft strategy, however, remains wedded to law enforcement, eradication, and interdiction, calls for strong federal support for local drug task forces, and explicitly rejects marijuana legalization. It also seeks to make drugged driving a top priority, which would be especially problematic if the administration adopts per se zero tolerance measures (meaning the presence of any metabolites of a controlled substance could result in a driver's arrest whether he was actually impaired or not).

Still, while the draft strategy is definitely a mixed bag, a pair of keen observers of ONDCP and federal drug policy pronounced themselves fairly pleased overall. While still heavy on the law enforcement side, the first Obama national drug strategy is a far cry from the propaganda-driven documents of Bush era drug czar John Walters.

The Good

"This is somewhat of a surprise, because for the first time they have included reducing the funds associated with the drug war in their strategy, although not in a big way, they're calling for reform of the crack/powder cocaine sentencing disparity, and they are calling for the reform of laws that penalize people," said Bill Piper, national affairs director for the Drug Policy Alliance. "This is the first time they've included anything recognizing that some of our policies are creating harm," he added.

"The stuff about syringe exchange and naloxone for overdose prevention is pretty good. It's the first time they've embraced any part of harm reduction, even though they don't use that name," Piper noted.

"I'm also impressed with the section on alternatives to incarceration," said Piper. "They basically said most drug users don't belong in jail, and a lot of dealers don't, either. It's still wedded to the criminal justice system, but it's good that they looked at so many different things -- drug courts, community courts, Operation Highpoint (warning dealers to desist instead of just arresting them as a means of breaking up open-air drug markets), programs for veterans. They seem interested in finding out what works, which is an evidence-based approach that had been lacking in previous strategies."

The Status Quo

"Drug war reformers have eagerly been waiting the release of President Obama's first National Drug Control Strategy," noted Matthew Robinson, professor of Government and Justice Studies at Appalachian State University and coauthor (with Renee Scherlen) of "Lies, Damned Lies, and Drug War Statistics: A Critical Analysis of Claims Made by the ONDCP." "Would it put Obama's and Kerlikowske's words into action, or would it be more of the same in terms of federal drug control policy? The answer is yes. And no. There is real, meaningful, exciting change proposed in the 2010 Strategy. But there's a lot of the status quo, too," he said.

"The first sentence of the Strategy hints at status quo approaches to federal drug control policy; it announces 'a blueprint for reducing illicit drug use and its harmful consequences in America,'" Robinson said. "That ONDCP will still focus on drug use (as opposed to abuse) is unfortunate, for the fact remains that most drug use is normal, recreational, pro-social, and even beneficial to users; it does not usually lead to bad outcomes for users, including abuse or addiction," he said.

"Just like under the leadership of Director John Walters, Kerlikowske's ONDCP characterizes its drug control approaches as 'balanced,' yet FY 2011 federal drug control spending is still imbalanced in favor of supply side measures (64%), while the demand side measures of treatment and prevention will only receive 36% of the budget," Robinson pointed out. "In FY 2010, the percentages were 65% and 35%, respectively. Perhaps when Barack Obama said 'Change we can believe in,' what he really meant was 'Change you can believe in, one percentage point at a time.'"

There is also much of the status quo in funding levels, Robinson said. "There will also be plenty of drug war funding left in this 'non-war on drugs.' For example, FY 2011 federal drug control spending includes $3.8 billion for the Department of Homeland Security (which includes Customs and Border Protection spending), more than $3.4 billion for the Department of Justice (which includes Drug Enforcement Agency spending), and nearly $1.6 billion for the Department of Defense (which includes military spending). Thus, the drug war will continue on under President Obama even if White House officials do not refer to federal drug control policy as a 'war on drugs,'" he noted.

The Bad

"ONDCP repeatedly stresses the importance of reducing supply of drugs into the United States through crop eradication and interdiction efforts, international collaboration, disruption of drug smuggling organizations, and so forth," Robinson noted. "It still promotes efforts like Plan Colombia, the Southwest Border Counternarcotics Strategy, and many other similar programs aimed at eradicating drugs in foreign countries and preventing them from entering the United States. The bottom line here is that the 'non war on drugs' will still look and feel like a war on drugs under President Obama, especially to citizens of the foreign nations where the United States does the bulk of its drug war fighting."

"They are still wedded to interdiction and eradication," said Piper. "There is no recognition that they aren't very effective and do more harm than good. Coming only a couple of weeks after the drug czar testified under oath that eradication in Colombia and Afghanistan and elsewhere had no impact on the availability of drugs in the US, to then put out a strategy embracing what he said was least effective is quite disturbing."

"The ringing endorsement of per se standards for drugged driving is potentially troubling," said Piper. "It looks a lot like zero tolerance. We have to look at this also in the context of new performance measures, which are missing from the draft. In the introduction, they talk about setting goals for reducing drug use and that they went to set other performance measures, such as for reducing drug overdoses and drugged driving. If they actually say they're going to reduce drugged driving by such and such an amount with a certain number of years, that will be more important. We'll have to see what makes it into the final draft."

"They took a gratuitous shot at marijuana reform," Piper noted. "It was unfortunate they felt the need to bash something that half of Americans support and to do it in the way they did, listing a litany of Reefer Madness allegations and connecting marijuana to virtually every problem in America. That was really unfortunate."

More Good

There are some changes in spending priorities. "Spending on prevention will grow 13.4% from FY 2010 to FY 2011, while spending on treatment will grow 3.7%," Robinson noted. "The growth in treatment is surprisingly small given that ONDCP notes that 90% of people who need treatment do not receive it. Increases are much smaller for spending on interdiction (an increase of 2.4%), domestic law enforcement (an increase of 1.9%), and international spending (an increase of 0.9%). This is evidence of a shift in federal drug control strategy under President Obama; there will be a greater effort to prevent drug use in the first place as well as treat those that become addicted to drugs than there ever was under President Bush."

Robinson also lauded the Obama administration for more clarity in the strategy than was evident under either Clinton or Bush. "Obama's first Strategy clearly states its guiding principles, each of which is followed by a specific set of actions to be initiated and implemented over time to achieve goals and objectives related to its principles. Of course, this is Obama's first Strategy, so in subsequent years, there will be more data presented for evaluation purposes, and it should become easier to decipher the ideology that will drive the 'non war on drugs' under President Obama," he said.

But he suggested that ideology still plays too big a role. "ONDCP hints at its ideology when it claims that programs such as 'interdiction, anti-trafficking initiatives, drug crop reduction, intelligence sharing and partner nation capacity building... have proven effective in the past.' It offers almost no evidence that this is the case other than some very limited, short-term data on potential cocaine production in Colombia. ONDCP claims it is declining, yet only offers data from 2007 to 2008. Kerlikowske's ONDCP seems ready to accept the dominant drug war ideology of Walters that supply side measures work -- even when long-term data show they do not."

Robinson also lauded ONDCP's apparent revelation that drug addiction is a disease. "Obama's first strategy embraces a new approach to achieving federal drug control goals of 'reducing illicit drug consumption' and 'reducing the consequences of illicit drug use in the United States,' one that is evidence-based and public health oriented," Robinson said. "ONDCP recognizes that drug addiction is a disease and it specifies that federal drug control policy should be assisted by parties in all of the systems that relate to drug use and abuse, including families, schools, communities, faith-based organizations, the medical profession, and so forth. This is certainly a change from the Bush Administration, which repeatedly characterized drug use as a moral or personal failing."

While the Obama drug strategy may have its faults, said Robinson, it is a qualitative improvement over Bush era drug strategies. "Under the Bush Administration, ONDCP came across as downright dismissive of data, evidence, and science, unless it was used to generate fear and increased punitive responses to drug-related behaviors. Honestly, there is very little of this in Obama's first strategy, aside from the usual drugs produce crime, disorder, family disruption, illness, addiction, death, and terrorism argument that has for so long been employed by ONDCP," he said. "Instead, the Strategy is hopeful in tone and lays out dozens of concrete programs and policies that aim to prevent drug use among young people (through public education programs, mentoring initiatives, increasing collaboration between public health and safety organizations); treat adults who have developed drug abuse and addiction problems (though screening and intervention by medical personnel, increased investments in addiction treatment, new treatment medications); and, for the first time, invest heavily in recovery efforts that are restorative in nature and aimed at giving addicts a new lease on life," he noted.

"ONDCP also seems to suddenly have a better grasp on why the vast majority of people who need treatment do not get it," said Robinson. "Under Walters, ONDCP claimed that drug users were in denial and needed to be compassionately coerced to seek treatment. In the 2010 Strategy, ONDCP outlines numerous problems with delivery of treatment services including problems with the nation's health care systems generally. The 2010 Strategy seems so much better informed about the realities of drug treatment than previous Strategy reports," he added.

"The strategy also repeatedly calls for meaningful change in areas such as alternatives to incarceration for nonviolent, low-level drug offenders; drug testing in courts (and schools, unfortunately, in spite of data showing it is ineffective); and reentry programs for inmates who need help finding jobs and places to live upon release from prison or jail. ONDCP also implicitly acknowledges that that federal drug control policy imposes costs on families (including the break-up of families), and shows with real data that costs are greater economically for imprisonment of mothers and foster care for their children than family-based treatment," Robinson noted.

"ONDCP makes the case that we are wasting a lot of money dealing with the consequences of drug use and abuse when this money would be better spent preventing use and abuse in the first place. Drug policy reformers will embrace this claim," Robinson predicted.

"The strategy also calls for a renewed emphasis on prescription drug abuse, which it calls 'the fastest growing drug problem in the United States,'" Robinson pointed out. "Here, as in the past, ONDCP suggests regulation is the answer because prescription drugs have legitimate uses that should not be restricted merely because some people use them illegally. And, as in the past, ONDCP does not consider this approach for marijuana, which also has legitimate medicinal users in spite of the fact that some people use it illegally," he said.

The Verdict

"President Obama's first National Drug Control Strategy offers real, meaningful, exciting change," Robinson summed up. "Whether this change amounts to 'change we can believe in' will be debated by drug policy reformers. For those who support demand side measures, many will embrace the 2010 Strategy and call for even greater funding for prevention and treatment. For those who support harm reduction measures such as needled exchange, methadone maintenance and so forth, there will be celebration. Yet, for those who support real alternatives to federal drug control policy such as legalization or decriminalization, all will be disappointed. And even if Obama officials will not refer to its drug control policies as a 'war on drugs,' they still amount to just that."

England: Royal College of Nursing Leader Calls for Prescription Heroin by the NHS

The head of Britain's largest nurses' union has called for the routine prescribing of heroin to addicts by the National Health Service (NHS) as a means of weaning them from their addiction. The remarks by Peter Carter, general secretary of the Royal College of Nursing (RCN), came after the RCN debated the idea at its convention in Bournemouth this week. No vote was taken.

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Peter Carter
Expressing his personal views after the debate, Carter, the former head of Central and North West London Mental Health NHS Trust, advocated for harm reduction measures as well as heroin prescription. He said he supported also supported needle exchanges and safe injection sites for intravenous drug users.

"The fact is heroin is very addictive," he said. "People who are addicted so often resort to crime, to steal to buy the heroin. It obviates the need for them to steal. It might take a few years but I think people will understand that if you are going to get people off heroin then in the initial stages we have to have proper heroin prescribing services. Critics say you are encouraging drug addiction but the reality is that these people are addicts and they are going to do it anyway," he added.

The most recent incarnation of heroin prescription calls began in 2002, when then Home Secretary David Blunkett first advocated for them. That call gave rise to pilot programs in London, Brighton, and Darlington in which users were provided with pharmaceutical heroin and allowed to inject under medical supervision. Those programs cut local crime rates by two-thirds over a six month period.

They also led to drug use and spending reductions. Of the 127 users involved in the pilot projects, three-quarters "substantially reduced" their use of street drugs, while their drug spending declined six-fold.

Carter's comments and the nurses' debate comes amid controversy and contention over how to deal with Britain's estimated 200,000 heroin addicts and just 10 days before British national elections. While all three parties have stressed alternative treatments for hard-core addicts, Conservatives have been attacking opiate maintenance programs, especially methadone maintenance, as morally bankrupt and are instead advocating for more abstinence-based programs.

At the RCN convention, Claire Topham-Brown, a nurse from Cambridgeshire, proposed the motion to support prescription heroin. It could be a means of harm reduction, she said, which despite some resistance from health professionals "has now become an accepted model of practice."

But not all delegates agreed. "Where would this stop, cannabis, cocaine, crack cocaine and other illicit substances? If we do this for heroin, do we have to do this for other substances, and can the NHS afford this?" asked Gayle Brooks, a member of the RCN's safety representatives committee.

Pain Medicine: Kansas Doctor and Wife Go on Trial in "Pill Mill" Case

A Kansas doctor and his wife who operated a pain management clinic in Haysville until their arrest by DEA agents in December 2007 went on trial in federal court in Wichita this week. Federal prosecutors charge that Dr. Stephen Schneider and his wife and nurse, Linda, ran a "pill mill" that illegally distributed pain-relieving drugs to addicted patients, but the Schneiders and their supporters say he is a compassionate doctor who provided high dose prescriptions to patients suffering from chronic pain because that's what they needed.

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PRN billboard defending the Schneiders
The Schneiders are charged under a multi-count indictment with conspiracy to illegally distribute drugs, money laundering, and health care fraud. Prosecutors say 68 of their patients died of drug overdoses and hold them responsible for 21 of those deaths. The Schneiders' attorneys say they were not responsible for any patient deaths.

The Schneiders and their supporters, including the Pain Relief Network, a national pain advocacy group, argue that they ran afoul of an overzealous federal prosecutor, Assistant US Attorney Tanya Treadway, who is improperly prosecuting them for their prescribing decisions. This prosecution, they say, is part of a broader attack on doctors who prescribe high levels of opioid pain medications by the DEA and federal prosecutors.

Treadway has also gone after the Pain Relief Network, first unsuccessfully seeking a gag order to block the group's leader, Siobhan Reynolds, from criticizing the prosecution, and then using an obstruction of justice investigation to demand that Reynolds turn over all documents related to the group's effort in the case. Reynolds initially refused, but relented after a contempt citation and accrued fines of $36,500.

In opening arguments this week in what is expected to be a two-month trial, Assistant US Attorney Treadway portrayed the Schneiders as greedy criminals. "This is a case about money, not medicine," she told jurors. Treadway said prescriptions were dispensed when Schneider was not president (but did not mention that physician assistants employed by the clinic could legally prescribe the drugs). "This caused abuse, overdoses, and deaths," she claimed.

Treadway even used the clinic's architectural style against the Schneiders, comparing its appearance to that of a Mexican restaurant. "And like a Mexican restaurant, people lined up at the door, waiting to get in," the prosecutor said.

But Stephen Schneider's attorney, Lawrence Williamson, likened the government's case the Dan Brown novel, "The Da Vinci Code," calling it "historical fiction." Williamson argued that the Schneiders were taking in Medicaid patients no one else would and billing the government more than any other doctor in the state. "He was costing them too much money," so the government decided to shut him down, the attorney argued.

While Treadway hammered on the 68 deaths among Schneider patients, Williamson pointed out that the practice had cared for more than 10,000 patients and was not aware of the extent of overdoses until federal prosecutors filed criminal charges against them.

Kevin Byers, representing Linda Schneider, who managed the clinic, said the couple were not guilty of the conspiracy charges. "The only thing they conspired in was a marriage," he said. "They ran a business together. That's the only conspiracy."

Stay tuned for more updates on the trial as it progresses.

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.

Europe: Heroin Maintenance Comes to Denmark

On Monday, Denmark opened its first heroin distribution clinic, two years after the Danish parliament passed a law legalizing the distribution of medicinal heroin. The opening was delayed until after the city of Copenhagen agreed to house the program.

Denmark thus joins Germany, the Netherland, and Switzerland, and to a lesser extent, Great Britain, as countries that allow for the provision of heroin to hard-core users who have proven unamenable to the traditional treatments, such as methadone maintenance. A pilot heroin maintenance program is also underway in Vancouver, Canada.

The Copenhagen clinic will serve about 120 of Denmark's 300 or so identified hard-core users. Only addicts who have been referred from a methadone treatment center will be accepted. While subjects will be prescribed heroin, they will have to consume it at the clinic.

"Our objective is not to cure heroin addicts, but to help those who are not satisfied by methadone by providing them with clean heroin, allowing them to avoid disease and the temptation of criminal acts to obtain the drug," a doctor and head of the clinic Inger Nielsen told Agence-France Presse. People in the program will get methadone for the first two weeks "so we can determine how much heroin to prescribe," she added.

The Danish User Association, a group that represents drug users, while supportive of heroin maintenance, criticized the program for requiring users to go to the clinic twice a day, seven days a week, to get their fixes. "This means living like a zombie, without being able to hold down a job or study or have hobbies," said head of the association Joergen Kjaer.

Europe: Anthrax-Tainted Heroin Death Toll Up to Ten

The death toll from anthrax-tainted heroin in Europe has risen to 10 as Health Protection Scotland confirmed that a heroin user who died in the Glasgow area on December 12 was infected with anthrax. Nine of the 10 deaths occurred in Scotland; the other occurred in Germany.

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anthrax spores
The latest announced death is actually the earliest. Prior to the announcement of this death, the earliest known death took place December 16.

At least 19 drug users -- 18 of them Scottish -- have been diagnosed with anthrax since the outbreak began. A pair of heroin deaths in Sweden turned out to be unrelated, and a cluster of deaths in Portugal has not been confirmed as being linked to anthrax.

While Scottish authorities have yet to find any anthrax-tainted heroin, they believe either the heroin itself or cutting agents have been contaminated with anthrax spores. They said there is no evidence of person-to-person infection.

"While public health investigations are continuing to attempt to identify the source of the contamination, no drug samples tested to date have shown anthrax contamination, although a number of other types of potentially harmful bacteria have been found," said Colin Ramsay, an agency epidemiologist. "It must therefore be assumed that all heroin in Scotland carries the risk of anthrax contamination and users are advised to cease taking heroin by any route. While we appreciate that this may be extremely difficult advice for users to follow, it remains the only public health protection advice possible based on current evidence."

As noted in our earlier story linked to above, harm reductionists have called for other measures, ranging from informational campaigns to liberalized prescribing of pharmaceutical heroin.

Infected patients typically developed inflammation or abscesses around the injection site within one or two days and were hospitalized about four days after that. In some severe cases, the lesions developed necrotizing fasciitis, a flesh-eating disease.

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.

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