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Heroin Maintenance: Study Suggests Baltimore Could Be Ripe for a Pilot Program

Baltimore is home to one of the nation's most intractable heroin-using populations, and now a study done for the city's Abell Foundation is suggesting it could be time to try something new, at least in this country: heroin maintenance. The idea is not so much to push for such a program now, but to open the door for discussion -- a worthy idea given that decades of repression and, more recently, conventional drug treatment have done little to stem the tide of addicts.

Authored by University of Maryland drug policy expert Peter Reuter, the study, Can Heroin Maintenance Help Baltimore?, examined existing heroin maintenance programs in Switzerland and Germany as well as the now-ended North American Opiate Maintenance Initiative (NAOMI) program in Vancouver, and examined the Baltimore heroin scene. His review of results so far found decreases in criminality, increases in employment, and health improvements for participants.

But Reuter also noted that those existing programs are expensive (more expensive than methadone treatment), serve relatively small numbers, and would be politically controversial in the US setting. In fact, the US National Institute on Drug Abuse, offered a chance to participate in the NAOMI program, declined. In addition, Reuter wrote that significant differences between hard core heroin users in Baltimore and in European cities made predictions of success difficult.

Can heroin maintenance help Baltimore? Here's how Reuter answered his own question:

At best there is a case only for an experiment. There are too many potential differences between Baltimore City and the other sites in which HAT [heroin-assisted therapy] has been tried to allow confident predictions of the outcomes. Visits to facilities in other countries hardly provide an inspiring model. The client population in Baltimore City is highly troubled so even if HAT leads to better outcomes for the group as a whole, many of the clients will remain unemployed, marginalized, and in poor health conditions. There will be some poster children but not many.

The potential for gain, however, is substantial. Even in the aging heroin-addict population, there are many who are heavily involved in crime and return frequently to the criminal justice system. Their continued involvement in street markets imposes a large burden on the community in the form of civil disorder that helps keep investment and jobs out. If heroin maintenance could remove 10 percent of Baltimore's most troubled heroin addicts from the streets, the result could be substantial reductions in crime and various other problems that greatly trouble the city. That is enough to make a debate on the matter worthwhile.

"It is a sensible innovation to consider," Reuter told the Baltimore Sun. "I am not a passionate advocate for it, but I do think someone should try it in the US. It has enough plausibility that it's worth trying."

But Baltimore officials are not convinced. "I think it would be a mistake to pursue an expensive and unproven idea when we need more resources for effective drug treatment," said Dr. Joshua Sharfstein, the city health commissioner, who apparently did not actually read the report. "There's nothing that persuades me to invest in something that is so expensive and without evidence."

Former Baltimore health commissioner Dr. Peter Beilenson worried that the notion was too radical to fly in the US and could undercut more plausible reforms. "It's not like everything has been tried and everything has failed and you just throw up your hands," said Beilenson, who is now Howard County's top health official. "The problem is if you are going to do any reasonable drug policy reform, this heroin thing is such a red flag that it takes all the attention away. It makes it look like anyone who is interested in drug policy reform is crazy." [Ed: Beilenson should know -- he tried it in 1998.]

But some addiction specialists said there should at least be a clinical trial. "Do I think it would be interesting? In a controlled clinical trial setting, yes," said Susan Sherman, an epidemiologist with the Johns Hopkins Bloomberg School of Public Health "To me, it's also important to have a public dialogue, regardless of the outcome. It forces people to deal with really hard issues about drug use and drug users."

"Most studies clearly show they help," said Dr. Christopher Welsh, assistant professor of psychiatry at the University of Maryland medical school. "But using public funds to fund something like this would be a whole other level of politics, especially in this economy."

Feature: It's Time for a New Drug Policy Paradigm, Say Latin American Leaders

A blue-ribbon commission of Latin American leaders has issued a report saying that the US-led war on drugs has failed and it is time to consider new policies, particularly treating drug use as a public health problem and decriminalizing marijuana. The report is an attempt to intervene not only in Latin American, US, and European drug policy debates, but also in the United Nations' ongoing 10-year review of global drug policies, which will culminate next month in a ministerial meeting in Vienna.
The report, Drugs and Democracy: Toward a Paradigm Shift, is the work of the Latin American Commission on Drugs and Democracy, a 17-member panel that includes former Brazilian President Fernando Henrique Cardoso, former Mexican President Ernesto Zedillo, and former Colombian President Cesar Gaviria. Other commission members include the writers Paulo Coelho, Mario Vargas Llosa, Sergio Ramírez and Tomás Eloy Martínez as well as leading scholars, media members and politicians.

Latin America is the leading exporter of both cocaine and marijuana. As such, it has faced the ravages of heavy-handed American anti-drug interventions, such as Plan Colombia and earlier efforts to destroy the Bolivian coca crop, as well as the violence of drug trafficking organizations and politico-military formations of the left and right that have grown wealthy off the black market bonanza. And while the region's level of drug consumption has historically been low, it is on the rise.

"The main reason we organized this commission is because the available evidence indicates the war on drugs is a failed war," said Cardoso at a Wednesday press conference in Rio de Janeiro to announce the report. "We need a different paradigm to cope with the problem of drugs. The power of organized crime is undermining the very foundations of democracy in some Latin American countries. We must acknowledge that these policies have failed and we must break the taboo that prevents us from discussing different strategies."

In the report, the commission calls for more humane and effective drug strategies. It emphasizes the following broad themes:

  • Treat drug use as a public health issue;
  • Reduce consumption through information and prevention actions;
  • Focus on enforcement against organized crime.

The commission also called on governments and civil society around the globe to "assess in the light of public health and advanced medical science the possibility of decriminalizing possession of marijuana for personal consumption."

"We need to break the taboo that's blocking an honest debate," Cardoso said, repeating one of the phrases of the day. "Numerous scientific studies show that the damage caused by marijuana is similar to that of alcohol or tobacco," said the well-respected former Brazilian leader.

"Decriminalization is only part of the solution," warned former Colombian President Gaviria. "You need to do what the Europeans are doing, which is helping addicts. That's what the US doesn't do; it just puts them in jail," he scolded. "You tripled the jail population in the US in the last 20 years because of prohibitionism. The half million people in jail because of drug consumption, is that reducing consumption?" he asked. "The excuse is that people commit crimes to get money, but you deal with that putting addicts under a doctor and helping them with their problem."

The commission has three objectives, said Gaviria. "We want to create a Latin American policy around the consumption of drugs, we want to promote a debate in the US -- we are very concerned that there is no real public debate on the politics of drug trafficking in US politics -- and we want the European Union countries to take more responsibility for drug consumption," he said. "They are not doing enough to reduce the consumption of drugs."

"This report represents a major leap forward in the global drug policy debate," said Ethan Nadelmann, executive director of the Drug Policy Alliance, who addressed a commission session in Bogotá last September. "It's not the first high-level commission to call the drug war a failure, nor is it the first time any Latin American leader has criticized the prohibitionist approach to global drug control. But it is the first time that such a distinguished group of Latin Americans, including three highly regarded ex-presidents, have gone so far in their critique of US and global drug policy and recommendations for what needs to be done."

The commission report is on "the cutting edge" of the global drug policy debate, said Nadelmann. "This is evident in its call for a 'paradigm shift,' in its recognition of the important role of harm reduction precepts and policies, in its push for decriminalization of cannabis, and in its critique of 'the criminalization of consumption.'"

Now it is on to Vienna -- and beyond -- said commission members. It is past time for a new approach, not only in the US, but internationally, they said.

"We hope the meeting in Vienna will not produce a result like previous meetings, where they just kept pushing back the date on which drugs will disappear," said Rubem Cesar Fernandes of the civil society organization Viva Rio. "The main discussion in Vienna should be whether the world should adopt European harm reduction policies. Most Latin American countries are supporting the approach of dealing with this as a health problem, not a criminal one."

Fernandes looked with guarded optimism at the new Obama administration. "We hope the Obama administration will at least be able to open that possibility because now the US totally opposes harm reduction as good policy," he said. "The world is not moving to follow the US jail policy. The US needs to think about whether putting people in jail is really solving the problem."

"Discussions in Vienna are not enough," said Cardoso. "We need national debates in all our countries, as well as inside the US. A clear dialog with the US is very important. We will try to get in contact with the Obama administration."

And so the pressure builds, on both the UN and the US. Will it be enough to force dramatic changes in Vienna or Washington? Probably not yet. But the global prohibitionist consensus is crumbling, clearly if slowly.

Europe: British Public Opinion Headed in Wrong Direction on Drug Policy, Poll Finds

If a comprehensive poll released last weekend is accurate -- and there is no reason to think it isn't -- British public opinion on drug policy is headed in the wrong direction. The poll conducted by ICM Research for the Observer and the Guardian newspapers found that public attitudes toward drug use, drug users, and drug sellers had grown decidedly more hard-line in recent years.

According to the poll, the proportion of people who think drug laws are "too liberal" has increased from 25% in 2002 to 32% now. At the same time, the number of people who think the drug laws are "not liberal enough" has dropped from 30% to 18%, and support for decriminalizing soft drugs has declined from 38% to 27%.

Respondents showed little sympathy for people who distribute drugs, whether they be professional drug dealers or merely sharing them with friends. About 70% said that all dealers should be treated the same -- with prison sentences. And 63% said drug addicts should be imprisoned.

Somewhat paradoxically, there is strong, though not majority, support for decriminalizing drug possession (38%) and making drugs available to addicts by prescription (44%).

Home Secretary Jacqui Smith told the newspapers hardening public attitudes were driven in part by concerns about stronger strains of cannabis. Both the Labor government and the British tabloid media have been engaged in a sometimes hysterical campaign to whip up fears about "skunk" in particular, as if that specific high-potency strain were somehow different from "regular" marijuana.

"This is a very important determinant of our decision to reclassify [cannabis from a Class C to a Class B drug]. This is a different drug even to that which was reclassified from B down to C [in 2003]," she claimed. "People are now beginning to recognize this isn't just some kind of harmless thing, but can have a serious impact on young people's mental health." People also realized marijuana production involved organized crime, she added.

But Martin Smith, the director of Drugscope, told newspapers the media and the government had falsely portrayed the drug problem as worse than it really was. "Although overall illegal drug use has been falling and significant progress has been made in tackling drug-related crime, many people believe the problem at best is getting no better," he said.

Europe: Swiss to Vote on Marijuana Decriminalization, Heroin Prescription

Swiss voters will go to the polls November 30 to decide whether to approve marijuana decriminalization and the government's ongoing "four pillars" drug strategy, which includes the prescription of heroin to hard-core addicts. A Swiss Broadcasting Corporation poll late last month showed the decriminalization effort in a virtual dead heat, leading 45% to 42%, with 13% undecided, while the referendum on the broader strategy appears headed to easy victory, with 63% in favor, 20% opposed, and 17% undecided.

The referendum on marijuana policy envisages its legalization for personal use, with its cultivation and sale being regulated by the state. It comes a decade after Swiss voters narrowly rejected a similar proposal. An attempt to decriminalize through parliament failed in 2004.

While the vote on decriminalization looks to be close, the effort is supported by a 1999 government advisory committee report and the governing coalition, and it is picking up some unexpected allies. Regulation would protect young people, argued the Social Democrats. Somewhat surprisingly, the effort is also supported by the center-right or libertarian Radical Party and the respected daily Neue Zurcher Zeitung, which described both the decrim effort and the amended drug law as steps in the right direction.

"A policy which is only based on abstinence, bans and repression ultimately leads to more spending on welfare. It also is against the spirit of liberalism and leaves no room for people to take responsibility for themselves," the newspaper editorialized.

But not everyone is jumping on the decrim bandwagon. The rightist Swiss People's Party remains staunchly opposed. "Switzerland would become the drug Mecca of Europe," said People's Party parliamentarian Andrea Geissbühler.

The government's four-pillars drug strategy appears much less controversial, especially after a decade of pilot heroin prescription programs that have proven effective. Even the grassroots of the rightist parties approve, according to the poll.

"The number of drug-related deaths per year dropped from 400 at the beginning of the 1990s to 152 last year," said Felix Gutzwiller, a Zurich Radical Party senator, adding that each year some 200 addicts graduate from heroin maintenance to methadone maintenance. "It is telling that drugs issues are no longer top of the list of public concerns, unlike 20 years ago," he said.

Chronicle Book Review: "The Cult of Pharmacology: How America Became the World's Most Troubled Drug Culture," by Richard De Grandpre (2007, Duke University Press, 294 pp., $24.95 HB)

Phillip S. Smith, Writer Editor
Phil Smith
Ritalin is a popular stimulant used to control the behavior of hyperactive children. It is legal, widely prescribed, and much adored by many parents and educators. Cocaine is an illegal stimulant, harshly penalized, and is reviled by the guardians of the common good. Yet Ritalin and cocaine act on the brain in a very similar fashion. In laboratory experiments, subjects -- human and animal -- do not differentiate between the two. So why is one legal and accepted and the other illegal and proscribed?

In other lab experiments, heroin users falsely told that their doses were being reduced reported withdrawal symptoms. Conversely, heroin users told their doses were being maintained when they were really being reduced showed no withdrawal symptoms. What's up with that?

In "The Cult of Pharmacology," drug researcher, former fellow at the National Institute on Drug Abuse, and author of "Ritalin Nation" Richard De Grandpre takes a serious crack at answering those questions. In a fascinating and provocative read, De Grandpre provides an illuminating social history of drug use in America, an eye-opening window into the legal drug industry, and a harsh, Szaszian critique of the increasingly popular disease model of addiction.

With American politicians poised to make the disease model of addiction official dogma by congressional fiat -- Sen. Joe Biden's (D-DE) bill that would define addiction as a brain disease is moving on Capitol Hill -- De Grandpre's intervention into the never-ending drug debate in America couldn't be more timely. Biden, along with a large portion of the biopharmacological research community and the American public in general are what De Grandpre would call victims of "the cult of pharmacology."
What is that? While in days of yore, drug actions were considered the work of spirits or demons, we have advanced beyond such silliness through science, right? We know that psychoactive drugs affect the brain in certain ways, right? Well, maybe not. In De Grandpre's own words:

"As a drug ideology derived from the eternal notion that psychoactive compounds contain a unique spirit or essence, the cult of pharmacology legitimized the belief that these spirits bypassed all social conditioning of the mind and by themselves transform human thought and action. Unlike other worldly modes of influence on mind and human experience, and despite many advances in the pharmacological sciences in the twentieth century, psychoactive substances continue to be treated in the main as spirits that could enter into a body and take possession of it. Yes, soul was transformed into mind and spirit into biochemistry, giving the appearance that science and medicine had done away with the myths surrounding what had come to be called 'drugs.' Drugs were not demythologized, however, but rather remythologized. Psychobabble and biobabble replaced magical explanations of drug action, creating what had become by the end of the century a new, molecular pharmacologism."

As De Grandpre illustrates with the heroin experiments, among many others, neither people nor lab animals necessarily respond to drugs in the predictable manner expected by the disease model. One of the most striking and well-known lab animal experiments gave monkeys unfettered access to cocaine, which some used until they killed themselves. But a much lesser known and remarked upon follow-up found that when the animals were given a chance to select another stimulus -- sugared water -- their cocaine use dropped dramatically.

I can't help thinking of the current wave of methamphetamine use and its destructive consequences in this context. As De Grandpre points out, Americans gobbled down billions of amphetamine tablets from the 1940s through the 1970s (when they were restricted, only to be replaced a few years later by Ritalin) without the horrid consequences that seem to obtain among tweakers these days. It's not the drugs that have changed -- amphetamines are amphetamines, and methamphetamine is an amphetamine -- but the social context and what De Grandpre calls the "placebo text" -- the set of beliefs one carries about how the drug is supposed to affect you -- that have changed.

Like lab rats in a sterile environment with no stimulus except cocaine, today's tweakers, and I'm speaking of the stereotypical Western and Midwestern poor, rural, white users (who as a South Dakotan I know well), may be so tweaked out not because of the pharmacological properties of the demon drug meth, but because of their sterile social environment and dim prospects… and because that's how meth's placebo text tells them to respond to the drug.

My mother and millions of women like her, on the other hand, took methamphetamines in the 1960s as a diet aid -- not a recreational drug -- and responded quite differently. Yes, she cleaned house like crazy and got pretty chatty, but she did not become "addicted" to the drug, nor did she engage in the kind of pathological behaviors associated with tweakers. Instead, she quit using it because she didn't like the fact that it kept her up at night.

Perhaps, as De Grandpre concedes, it is not only set and setting that make the difference. While he doesn’t directly discuss the pharmacodynamics of meth, in his discussion of Ritalin and cocaine, he notes studies suggesting that the manner of ingestion of the drug (oral, say, versus injected or smoked) can have an effect on the drug user's experience. My mother wasn't shooting up or smoking speed, she was popping little yellow pills.

Was it the placebo context that kept my mother from tweekerdom? Was it the fact that she swallowed pills instead of injecting powders? Or that she took small doses instead of large ones? We don't know. What De Grandpre convincingly argues is that we do (or should) know that it is not something deterministically inherent in the methamphetamine molecule that caused her (and millions of other slightly overweight women in the 1960s and 1970s) to walk away from it, but made poor, rural, white people into tweakers in the 1990s and 2000s.

My mother was fortunate. Her drug use was sanctioned. If she had been taking the same drugs illegally, she would have faced prison. As De Grandpre notes, that's because the last century saw a bifurcation in dealing with drugs: Some drugs -- notably heroin, cocaine, and marijuana -- are "demon drugs," full of pharmaceutical malice, ready to enslave the unwary user, while others, notably the prescription pharmaceuticals, are "angel drugs," here to save us from the troubles of the day with their molecular magic.

We can thank the American Medical Association and the pharmaceutical industry for that, according to De Grandpre. Rather than being rivals for market share, as was the case in the era of patent medicines before the Food and Drug Act of 1906, the two groups decided to split the booty. The pharmaceutical companies would develop and market psychoactive drugs and the doctors would sanction and prescribe them as "ethical medicines" as opposed to dangerous drugs.

This historical process gave rise to "differential prohibition," or the demonizing of some drugs and the sanctifying of others -- even if, like Ritalin and cocaine, they are essentially the same thing -- as well as to the two faces of an authoritarian state: the therapeutic state that classifies drug taking as a disease and wants to treat it, often with other drugs and the prohibitionist state that sees drug use as immoral and wishes to punish it.

There is much, much more to "The Cult of Pharmacology." Even as a wizened veteran of the drug scene, there is much that challenges my beliefs and preconceptions about drugs and their interactions with humans. De Grandpre's theses may be controversial and even unpopular in this period when much of the mainstream political discourse seems to consist of calling for treatment instead of prison and for dealing with drug "addicts" as victims instead of miscreants. But he should definitely be read by anyone concerned with drug policy in America and why it's gone so terribly awry.

Make Heroin Free On Health Service

United Kingdom
Gloucestershire Echo (UK)

Europe: Scottish Police Chief Says Time to Consider Prescribing Hard Drugs

A leading Scottish police official has inserted himself into the ongoing debate over drug policy in Scotland by saying that law enforcement alone is not working and that drug courts and even the prescribing of Class A drugs to users should be considered. John Vine, Chief Constable of Tayside Police made the remarks in a Monday interview with BBC Scotland.
John Vine
"I don't think we are winning the war against drugs just by enforcement alone," Vine said. "We need to continue that effort and reassure communities that we are going to be there for them but we also need to talk to politicians and health authorities to see whether we can do something differently to reduce the demand for Class A drugs," he said.

"I would like to see, for example, drugs courts being set up in the area and would also like to see possibly some debate about whether prescribing Class A drugs might be something the health authorities might consider."

Ecstasy, LSD, heroin, cocaine, crack cocaine, magic mushrooms, and injectable amphetamines are all considered Class A (most serious) drugs under the United Kingdom's drug classification scheme. But it is likely Vine is talking about heroin, and possibly cocaine and amphetamines, the illicit drugs that are associated with the greatest social problems in Scotland.

Heroin seizures had tripled in Tayside in recent years, Vine said. While his police force can continue to produce good arrest figures, he added, it is time for a dialogue between law enforcement, health authorities, and politicians to come up with a long-term solution. That may not be a popular notion, he said, but he would be willing to experiment in Tayside.

"There are people who will have a view as to whether this would be socially acceptable or whether this would have any chance of working," Vine told BBC Scotland. "I would like this force and this police area to be a pilot area for any initiative which might be regarded as innovative or risky which could be evaluated by experts to see whether we can reduce demand for acquisitive crime."

Perhaps the Scottish new prime minister of Britain will lend Chief Vine an ear.

Police chief's radical drugs call

United Kingdom
BBC News

Afghanistan, Plan Colombia and Drug Eradication: Problems and Solutions

Recent increases in opium production in Afghanistan presents a Catch-22 to U.S. policymakers. On the one hand, a November 2006 United Nations and World Bank report found that forced eradication of opium crops is driving poor Afghans into the hands of the Taliban, empowering crime syndicates and destabilizing the country. On the other hand, doing nothing about the heroin trade allows major drug traffickers to enrich themselves unfettered. Is there a third option? Rep. Carnahan has suggested licensing Afghan farmers to grow opium for legal pain medications, the way the international community diminished the drug trafficking problem in India and Turkey. Senator Sununu has suggested the U.S. buy the opium crops from the farmers and destroy them. Senator Biden has suggested switching the focus away from poor farmers towards disrupting the drug cartels that are moving the drugs. Some experts suggest building roads and schools and providing alternative employment to poor Afghans. Others suggest ending drug prohibition all together. This panel explores the problems posed by both opium production and opium eradication and offers possible solutions. It looks at not only what is going on in Afghanistan right now, but lessons that can be learned from eradication policies in Latin America and elsewhere. Speakers include: Vanda Felbab-Brown, Ph.D. - Research Fellow at the the Brookings Institution Ted Galen Carpenter - Vice President for Foreign Policy and Defense Studies at the Cato Institute Ethan Nadelmann – Executive Director of the Drug Policy Alliance Sanho Tree – Director of the Drug Policy Project at the Institute for Policy Studies. Please RSVP to Grant Smith at [email protected] or 202-216-0035. Space is Limited. Snacks and beverages provided
Tue, 04/24/2007 - 12:00pm - 1:00pm
Washington, DC
United States

Opinion: Still seeking some relief

United States
The Record (CA)

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