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Southeast Asia: Methadone Maintenance Coming to Ho Chi Minh City

Vietnam has generally appeared in these pages in recent months because of its penchant for using the death penalty on drug traffickers, but now Vietnamese authorities have taken a step in a different direction, at least when it comes to users. Last Friday, officials in the capital, Ho Chi Minh City, announced that a methadone maintenance program for opiate users will be getting underway there.

In remarks reported by VietnamNet, Ho Chi Minh City Health Department Deputy Director Le Truong Giang announced that the Ho Chi Minh City AIDS Committee will start providing methadone to heroin users beginning next month. The one-year program sponsored by the World Health Organization will operate out of community counseling centers in several districts in the city, Giang said.

The program in Ho Chi Minh City will be the second to operate in Vietnam. For the past year, some 700 drug users in the northern port city of Haiphong have been participating in a pilot program funded by the US and British governments. That program will end at the end of this year.

Giang said that results from methadone maintenance programs in Australia, China, and Indonesia all showed that providing heroin users with access to methadone maintenance therapy would dramatically reduce crime. Methadone is provided for free to users, he added. If the Ho Chi Minh City and Haiphong programs are proven to be effective, they would be expanded, Giang said.

Middle East: Tel Aviv Seeks to Begin Heroin Maintenance Program

The Israeli city of Tel Aviv is moving to establish a pilot heroin maintenance program for older addicts who have proven resistant to recovery. Then the city's existing opioid maintenance programs, which now offer methadone and subutex, will have one more option in dealing with hardcore heroin users.

According to the Tel Aviv News, the city's social services division has formulated the program and the city has already drafted a position paper in support of the program. According to the plan, the heroin will be dispensed at carefully monitored clinics that will also provide medical and psychological services to their clients. Tel Aviv officials will soon present the proposal to the Israeli Ministry of Health for approval.

The program will cut crime, the city argued, citing statistics finding that 75% of property crimes are committed by addicts looking for their next fix. "Many addicts therefore lose control and find themselves unwitting criminals," stated the Tel Aviv Municipal Anti-Drug Authority's position paper.

The city also reported that only 20% of heroin users who entered a treatment program remained drug-free. "Fighting addiction demands immense mental and physical fortitude that many addicts simply don't possess," said Dr. Benny Avrahami, director of the anti-drug authority, who drafted the position paper.

The program could bring many advantages, including providing stronger support for addicts and their families, a reduction in the economic cost of treating them, a reduction in crime, and the use of clean, laboratory-produced heroin. If Israeli authorities approve the pilot program, Israel will join a select group of European countries, including Germany, Switzerland and the Netherlands, where such program have consistently resulted in a decline in property crime, as well as improvements in clients' heath and welfare. Also allowing experimentation with heroin maintenance are Great Britain, which restarted it last year more than a decade after the conservative government of Margaret Thatcher had shut it down, and Canada, where the Vancouver North American Opiate Maintenance Initiative (NAOMI), is the only such program in North America.

Opiate Maintenance: Open Season on Methadone Clinics and Clients in the Indiana Legislature

Indiana's methadone clinics and their clients are the target of close scrutiny by the state House of Representatives. Last month, the state Senate passed a bill, SB 174, that would tighten state regulation of the clinics, where people attempting to wean themselves from dependence on opiates are administered or allowed to take home doses of methadone as a substitute opioid.

The Senate bill may represent reasonable regulation of an industry in which some 10,000 people participate in Indiana, but it's a different story in the House. While the bill as passed in the Senate restricted itself to requiring clinics to adhere to state and federal law, register with the state, and meet certain record-keeping requirements, the House is trying to micro-manage not so much the clinics, but their clients.

On Tuesday, the House Health Committee unanimously passed SB 157, but not before approving amendments requiring that patients be tested for marijuana and that they have a designated driver after appointments. The committee narrowly defeated another amendment that would have barred patients from bringing their children with them to the clinics.

According to remarks reported in the Louisville Courier-Journal, the sponsor of the designated driver provision, Rep. Steve Stemler (D-Jeffersonville), said he added it because the FDA considers methadone in the same class of drugs as heroin, Oxycontin, and other opioids. Hospitals and medical centers require patients taking these medicines after outpatient surgeries and other procedures have a designated driver.

One witness, John Dattilo, who lives near the Southern Indiana Treatment Center, told the committee he is concerned about the safety of his family as they travel down a road with hundreds of methadone patients each day. "It's all about safety to me," he said. "We need help. We do need to put some restrictions on this."

But Tim Bohman, regional manager for the health care corporation that owns that clinic, told the committee patients have a high tolerance for opioids and can function normally after treatment.

At least one committee member, Rep. Carolene Mays (D-Indianapolis), worried the measure could push patients away from the methadone clinics. "I'm concerned we'll lose people in treatment who are riding a bus or walking or don't have a designated driver," she said.

Marijuana testing of methadone patients is necessary because some neighboring states require it, said Rep. Stemler. Indiana should not be a magnet for addicts from elsewhere because of its loose methadone laws, he said.

Indeed, about half of the 10,000 patients served by the state's clinics come from out-of-state. But perhaps that's not so shocking given the state's geographic position. At its northwest corner is Chicago, to the near northeast is Detroit, to the near southwest is Cincinnati, and directly across the Ohio River to the south is Louisville.

At least the committee rejected one more attempt to micro-manage methadone patients, an amendment by Rep. Terry Goodin (D-Crothersville) that would have banned patients from bringing their children to clinics. It was supported by Clark County Commissioner Michael Moore, who testified that "too many" patients bring their children with them when they come in early in the morning for treatments. Moore, who owns a restaurant near a clinic, said that he often saw them dozing off or acting erratically before or after treatment. "This is the kind of behavior that would make most social-service agencies jump in and act," Moore said.

But Rep. John Day (D-Indianapolis) managed to blunt Goodin's amendment, saying he worried that a single parent might have to miss an appointment if she could not bring her children. "That's a very real dilemma," Day said.

While Goodin then withdrew his amendment, saying it did not have enough support to pass, he said he would offer a similar proposal later.

This isn't the first time opiophobia has reared its head in the Indiana legislature. Last year, the legislature voted to enact a moratorium on new clinics. But this is the first time the legislature has zeroed in on patients -- with measures ostensibly designed to protect the public safety but whose real world result would be to drive patients away from the clinics.

Europe: British Drug Council Calls for Heroin, Cocaine Prescribing By Nurses, Pharmacists, Chides Government's Drug Strategy Consultation

The British Advisory Council on the Misuse of Drugs (ACMD) has criticized the Labor government's ongoing consultation on a new 10-year drug strategy as a "missed opportunity" because the government created a consultation paper that was "self-congratulatory" and focused on trying to claim the current 10-year strategy is a success. A day later, the ACMD's head announced the council was recommending that doctors be allowed to prescribe controlled substances such as heroin and cocaine.

In its response to the consultation, the ACMD was decidedly undiplomatic in its overall comments: "It is unfortunate that the consultation paper's 'key facts and evidence' section appears to focus on trying to convince the reader of success and progress; rather than providing an objective review and presentation of the current evidence. The ACMD found the consultation paper self-congratulatory and generally disappointing," the council complained.

The ACMD also scolded the government for lacking a firm evidence base and failing to acknowledge it: "It is of concern that the evidence presented, and the interpretation given, are not based on rigorous scrutiny. It is not acknowledged that in many cases the information is uncertain and sometimes of poor quality. It is disappointing that the consultation paper makes no mention of needing to improve the evidence base of drug misuse and treatments nor makes use of international evidence, for informing and guiding policy," the council chided.

"We consider that an opportunity has been missed to address the public health problem relating to drug misuse and the balance with law enforcement and the criminal justice system. We would also have welcomed a statement of ambition for the drug treatment system," the council added.

The ACMD was created as part of the 1971 Misuse of Drugs Act and it is mandated to advise the Home Office on drug policy. One of its primary functions is to recommend which classification various drugs should go in. While the ACMD is critical of the government's drug policy consultation process, it itself has been criticized for a lack of scientific basis in the drug classification system, most thoroughly by the Science and Technology Select Committee's 2006 report, Drug Policy: Making A Hash of It?

The ACMD's caustic words for the process gave fuel to the political opposition, with the Liberal Democrats quick off the mark. "The failures of the government's drugs policy are laid bare for all to see when their own advisory committee condemns the Home Office as being misleading and self-congratulatory," said Liberal Democrat leadership contender Nick Clegg. "When will the government wake up and acknowledge something many members of the public know: we are losing the war on drugs?" Clegg asked.

It wasn't just political foes. Steve Rolles of the Transform Drug Policy Foundation had last month called the consultative process "a sham," saying the government had already made up its mind to continue the current strategy. "The consultation process behind the new strategy has been woeful," he said.

Then, last Saturday, ACMD chairman Sir Michael Rawlins announced during the group's first public meeting in its 36-year existence that he had sent a letter to the Home Office proposing that the drug law be changed to allow nurses and pharmacists prescribe heroin and cocaine to hard-core users and pain patients. He wrote a letter to Home Office minister Vernon Coker making the proposal in a bid to help patients manage pain better, he said.

That proposal prompted quick criticism, too, this time from political opponents on the right, who called it a "white flag" approach. "If Gordon Brown signs up to this, it would show yet again that Labour merely seek to manage drug addiction rather than end it," said Conservative shadow home secretary David Davis. "The Conservative approach is different. We would stop -- not swap -- drug addiction by focusing the drugs budget on expanding the use of abstinence-based drug rehabilitation programs. This method has proved far more successful at getting people off drugs than the Government's white flag approach."

And so it goes in the countdown to the new British drug strategy, which is due in the spring. Meanwhile, the ACMD is considering whether ecstasy should be down-scheduled and marijuana up-scheduled. The drug debate in Britain is going to stay lively for awhile.

Europe: British Heroin Maintenance Trials a Success, Researchers Say

Initial results from a pilot heroin maintenance program in London, Brighton, and Darlington suggest it has reduced drug use and crime, researchers said over the weekend. In the program, which is funded by the Home Office and the Department of Health, some 150 hard-core heroin users are given either oral methadone, injected methadone, or injected heroin.

According to trial leader Professor John Strang of the National Addiction Center, about 40% of participants had left the street drug scene behind. "Of those who have continued, which obviously is a disappointment, it goes down from every day to about four days per month," he told the BBC.
"Their crimes, for example, have gone from 40 a month to perhaps four crimes per month.
"The reduction in crime is not perfect but is a great deal better for them and crucially a great deal better for society."

While the findings are preliminary -- final results are not expected for another year -- they are in line with similar findings from heroin maintenance programs in Holland and Switzerland. In both countries, researchers have reported a reduction in criminality by program participants.

In the British program, hardened addicts were reported to be leading more normal lives and enjoying better family relationships because they were no longer going in and out of prison. The annual cost per patients is about $18,000 to $30,000, about three times the cost of methadone maintenance, but presumably much cheaper than having users acquire their drugs on the black market, along with the criminality associated with black market drug use.

"With this treatment we're looking at having a very secure way of providing the treatment which enables the patient to break out of their addiction and is also very safe to the community," said Strang. "What we're looking at doing is enabling people both to quit their involvement with crime and to quit their involvement with street heroin use."

NAMA Press Release: FOX Philadelphia News Story Stigmatizes Patients Receiving Methadone Treatment

FOR IMMEDIATE RELEASE: November 16, 2007 CONTACT: Joycelyn Woods, Executive Director, t: 212-595-6262, E: [email protected] or Roxanne Baker, President, T: 212-595-6262, E: [email protected] FOX Philadelphia News Story Stigmatizes Patients Receiving Methadone Treatment The FOX Philadelphia news story that aired on November 13, 2007 regarding the illegal sales of methadone in Camden, NJ is disappointing. Once again the news media is airing negative sensational stories about methadone and ignoring the thousands of positive ones. The vast majority of patients in the nation’s methadone treatment programs are not criminals. The National Alliance of Methadone Advocates (NAMA) urges you to appreciate that the great majority of patients receive their methadone from licensed accredited programs, are responsible in handling their medication, compliant with their treatment plans (including abstinence from illicit substances) and live lives that are virtually indistinguishable from your own. Methadone has provided a bridge to sustained recovery from chronic opiate addiction for hundreds of thousands of others during its forty-year history. This bridge has allowed us to leave the instability and chaos of active addiction in the past and to seek out challenges as professionals, business people, artists, students, family members and taxpayers. However, due to continued negative portrayal of methadone treatment in the media such as the Fox broadcast there is a tendency for the public to form distorted images of methadone patients. There are thousands of compliant patients who are grateful for methadone treatment and eager to see it accurately reported by the media but remain silent because they have families and other responsibilities to consider. They are well aware of the stigma and prejudice that methadone patients experience daily and are afraid that the sensationalized media such as a Fox Philadelphia story could harm their family and career. The media never acknowledges the successes because it is not exciting. Consequently, the negative perception goes unchallenged and it makes it that much more difficult for those of us who benefit from methadone treatment to present the true picture. Since its’ beginning over 40 years ago methadone maintenance has been the most effective treatment for narcotic addiction. In spite of its success, methadone maintenance is often disparaged as a "substitute drug" by those who ignore the positive benefits that it has clearly brought to society. Such attitudes negatively impact on methadone treatment in a variety of ways, but it is the methadone patients themselves who are particularly stigmatized and harmed. Patients are mistreated and misinformed and considered as social outcasts. They are victims of discrimination in health care, the job market, education, insurance and housing. The National Alliance of Methadone Advocates (NAMA) was organized as a formal mechanism for methadone patients to voice their own needs and to form a strong, unified public presence on their behalf. The primary objective of NAMA is to advocate for the patient in treatment by destigmatizing and empowering methadone patients. First and foremost, it can confront the negative stereotypes that impact on the self-esteem and worth of many methadone patients with a powerful affirmation of pride and unity. Website:
Philadelphia, PA
United States

Europe: German States Want Heroin Maintenance for Addicts

German state governments are pressing the government of Chancellor Angela Merkel to open the way to providing free heroin for hard-core addicts throughout the country. A bill adopted in the Bundesrat and supported by 13 of the 16 state governments would transform what is now officially a heroin maintenance pilot program where hundreds of addicts in seven cities are provided free heroin into a national program paid for by health insurers.

Established in 2001 in an effort to help hard-core addicts get off the drug, reduce their levels of criminality, and reduce overdose deaths and disease, the the pilot program was deemed a success by the German government in May 2006. Plans were announced to expand it from 750 to as many as 1,500 people, but those apparently never materialized.

A federal drug official who supports broadening the program, Sabine Bätzing, told Deutsche Presse Agentur, said some 3,500 addicts would benefit from the program if it were available across the country. As with the pilot program, only those addicts who had failed on substitutes such as methadone would be eligible for the expanded program.

Birgit Schnieber-Jastram, social-welfare minister in Hamburg, told the news agency that pilot programs in her state had reduced drug consumption and helped break the link between addicts and illicit drug markets.

But the bill to expand the heroin maintenance program faces the opposition of Merkel's dominant Christian Democratic Union, which objects to the burden it says it would impose on insurers and is instead suggesting more pilot projects on an as needed basis. The CDU also argues that the aim of German heroin policy should be to wean addicts from heroin, not maintain them.

Drug War Chronicle Book Review: "The Heroin Solution" by Arnold Trebach (2nd ed., 2006, Unlimited Publishing, 330 pp., $19.99 pb.)

Phillip S. Smith, Writer/Editor

(Click here to order "The Heroin Solution or other books by Arnold Trebach through DRCNet's latest book offer.)

When "The Heroin Solution" was first published by Yale University Press a quarter-century ago, it got rave reviews from the likes of the New York Times and Publishers Weekly. It was a mindblower. For the vast majority of readers, Arnold Trebach opened a window into an astonishing world they had never before imagined, one where -- gasp! -- doctors, not policemen, dealt with heroin and heroin users.
Trebach, who from his base at American University began influencing a generation of disciples and who founded the Drug Policy Foundation (the progenitor of the Drug Policy Alliance) in 1986, is now known as the grand old man of the American drug reform movement, and the success of "The Heroin Solution," along with his 1987 "The Great Drug War," played a big role in cementing that reputation.

What Trebach did in the "Heroin Solution" was tell three interwoven stories: the story of heroin, the story of the American approach to heroin, and the story of the British approach to heroin. For many, that book was an awakening, a realization that there was an alternative to what by 1982 was already being reviled as an atrocious and failing policy of prohibition and repression. Where the American system denied that heroin had any medical utility whatsoever and jailed physicians, junkies, and hapless pain patients alike, the British system was kinder and gentler, with doctors given considerable latitude to prescribe heroin even -- and especially -- in cases where they knew they were only allowing their patients to maintain their addiction.

Now, "The Heroin Solution" is out in a second edition, the last volume of the "Trebach Trilogy," which also includes the reprinted "The Great Drug War" and last year's "Fatal Distraction." But this edition of "The Heroin Solution" is not a substantive reworking of the material; the only addition to the original volume is a new preface.

It still makes timely and compelling reading, but the reason why is hardly good news. "The Heroin Solution" is still relevant because we have progressed so little since it was written. The issues Trebach addressed in 1982 are, in many cases, the same issues we face today. Much has happened, but little has changed, and much of what has changed has changed for the worse.

In Britain, which Trebach described as a model of an enlightened (if not perfect) approach to heroin, the heavy hand of the state and governing medical bodies has slowly shrunk the space in which doctors may prescribe heroin. When Trebach wrote, probably a few thousand British addicts were being prescribed heroin; in his new preface, he estimates that perhaps 500 are. For all the talk of opiate maintenance in Britain, it seems like for the past quarter-century it seems like it's been one step forward, one step back.
Arnold Trebach at 2003 press conference on which DRCNet collaborated
Trebach decried the cruel and inhumane treatment of physicians and pain patients alike in "The Heroin Solution." If anything, the problem has gotten worse in the intervening quarter-century. One thing the book offers, though, is some perspective. The latest round of pain doctor persecutions smell remarkably similar to those of doctors Trebach mentioned operating back in the 1930s. It's a similarity Trebach notes himself in his preface to the new edition, where he cites the case of Dr. William Hurwitz, who just weeks ago was convicted again on federal drug charges for loose prescribing practices and faces possible decades in prison. (He's already been in for two years.)

Trebach asked in 1982 where America found itself nearly seven decades after passage of the Harrison Narcotics Act, and was not happy with the answer. It's much worse now. Back then, Trebach complained that the federal government spent $6 billion fighting the drug war in the 1970s; now $6 billion would fund the federal drug war for about three months. Since then, the prison population of the United States and the number of drug prisoners has gone through the roof. You know the drug war litany.

Trebach does, too, and that is part of the reason his thinking about drug prohibition has evolved over time. When he wrote "The Heroin Solution" in 1982, he called only for doctors to be allowed to prescribe heroin. Now, he is a full-blown anti-prohibitionist. Lack of progress on reforming US drug policy breeds more radical responses.

A revised and updated "The Heroin Solution" would be nice. There could be new chapters on the cutting-edge work on heroin maintenance going on in Switzerland and Germany, Spain and the Netherlands; the rise of safe injection sites; the trials in Vancouver; the spread of heroin addiction in Iran, Pakistan, and the Central Asian republics; and contemporary use patterns in the West, among others.

But 25 years after it was first published, "The Heroin Solution" is still relevant, still revelatory, and still a good read. Or, as Publishers Weekly said the first time around, "A blockbuster!"

(Click here to order "The Heroin Solution or other books by Arnold Trebach through DRCNet's latest book offer.)

Cure for drug woes?

Vancouver, BC
Canoe Network (Canada)

Europe: Heroin Substitute Buprenorphine Now Available in Scotland

A Scottish government agency has approved the use of the heroin substitute buprenorphine as a replacement for heroin users unable to take the more common substitute methadone. A tablet form of the drug, Suboxone, is now available through the National Health Service.
now-outdated European buprenorphine availability chart, from the EMCDDA web site
Although buprenorphine is widely used in England, Europe, and Australia, and is available with restrictions in the United States, it had been banned in Scotland since the mid-1980s because it had been abused by users who heated and injected it to get high. But Suboxone will, according to its manufacturer, cause withdrawal symptoms if injected, easing fears of abuse.

The Scottish Medical Consortium, the agency that decides which drugs can be prescribed, has approved Suboxone only for patients for whom methadone is not suitable. It also requires that Suboxone maintenance stand place only "within a framework of medical, social, and psychological treatment."

Drug experts interviewed by the newspaper the Scotsman generally thought it was a good thing, although at least one advocated abstinence instead. The decision was welcomed as a "useful addition" by David Liddell, director of the Scottish Drugs Forum. Andrew Horne, of the drug treatment charity Addiction Scotland, said: "We think it is a useful alternative and will complement the rehabilitation work we do."

But opiate maintenance is "part of the problem," said Neil McKeganey, professor of drug misuse research at Glasgow University. "We have a large number of people on substitute medications and here is another substitute drug; it will still leave us with too few abstinence-focused drug treatments."

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