Representatives of 19 international and regional harm reduction organizations meeting in Toronto this week have issued a declaration calling for immediate action to address the spread of HIV through injection drug use. Known as the Declaration of Unity, the statement demands that governments and international anti-drug organizations stop impeding the adoption of harm reduction measures proven to reduce the spread of disease, such as needle exchanges and safe injection sites.

The groups urged governments to:

• provide adequate coverage and low threshold access, including in correctional settings, to sterile injection equipment, condoms, methadone and buprenorphine as essential components of comprehensive HIV prevention and care;
• ensure that drug users and all marginalized populations have equitable access to quality HIV prevention, medical care, and highly active antiretroviral treatment, that concrete country-level and global targets be established, and that progress be monitored;
• provide meaningful involvement of drug users at all levels of planning and policy, and financial support for their organizations; and
• put an end to disenfranchisement and human rights violations of drug users including mass imprisonment, punitive and degrading drug treatment programs, and the widespread use of withdrawal as a form of coercion.

Noting that UNAIDS cannot effectively slow the spread of HIV when forces within the UN system are creating obstacles to effective harm reduction measures, the groups demanded that:

• the United Nations Office on Drugs and Crime, as the UN agency tasked with leadership on HIV prevention among drug users, ensure that effective community protection against HIV is not ignored in the name of drug control and law enforcement;
• the International Narcotics Control Board, as the body charged with responsibility for monitoring implementation of the drug treaties, publicly and unambiguously endorse and promote harm reduction as an approach consistent with those treaties and monitor global delivery of substitution treatment and HIV prevention measures for drug users;
• the international community and all major UN bodies involved in drugs and HIV approach drug use as a health and social matter which also requires some law enforcement interventions rather than being primarily a matter of criminal justice.

The harm reductionists from around the globe were in Toronto for the International AIDS 2006 conference. "HIV is being spread increasingly -- in some parts of the world, chiefly-through the sharing of injecting equipment, said Dr. Diane Riley, who signed the declaration on behalf of the Canadian Foundation for Drug Policy and the Youth Network for Harm Reduction International. "Considerable evidence exists that harm reduction strategies such as needle exchange programs can effectively, safely and cheaply reduce the spread of HIV; yet very few such programs are in place. Governments are in effect spreading infection through their own drug control and enforcement policies which encourage use of non-sterile equipment, and marginalization and incarceration of users," Riley added in a press release announcing the declaration.

"The United States, the world's most important donor of international aid, restricts implementation of harm reduction strategies," Riley charged. "Political and social commitment, including commitment of the necessary resources, and an end to the US administration's embargo on harm reduction are needed now," Riley said. "If we fail to do this, further catastrophe is inevitable and the global economy will simply not be able to cope with the resultant burden."

Boston public health authorities will likely approve a trial program providing heroin users with naloxone (brand name Narcan) next week, the Boston Globe reported Wednesday. If the Boston Public Health Commission indeed approves the program, it will join cities such as Baltimore, Chicago, and New York where authorities have already approved its distribution to drug users.

"The number one hope with this is to save lives," Public Health Commission executive director Joel Auerbach told the Globe. "Our paramedics have said it's a miracle drug. They've seen people who are comatose who are then revived and perfectly fine."

The trial run is expected to enroll 100 heroin users, who would have to undergo training and evaluation, as well as listen to encouragements to quit. But if they were not prepared to stop using, they would be instructed in how to administer Narcan. Then they would be given a prescription for two doses.

The proposed move comes just a week after the Office of National Drug Control Policy -- the drug czar's office -- rejected the idea as somehow encouraging drug use. "We don't want to send the message out that there is a safe way to use heroin," ONDCP spokesperson Jennifer DeVallance told the AP.

David Borden, Executive Director

David Borden

The refreshing truth-telling came from Great Britain, where a Parliamentary Committee harshly tore into the official drug classification scheme used in the Misuse of Drugs Act, and the agency that is responsible for maintaining it. Many of the rankings seemed to have resulted from "knee-jerk responses to media storms," the committee charged, with no consistency and "no solid evidence to back-up the view that classification had a deterrent effect." "The current classification system is riddled with anomalies and clearly not fit for its purpose," the chairman said. "From what we have seen, the Home Office and ACMD approach to classification seems to have been based on ad hockery and conservatism." (See two articles below in this issue to read all about it.)

Gotta like that! But now for one that I don't like -- not at all. In Philadelphia, one of the cities suffering under the crisis of fentanyl-laced heroin and the resulting wave of often fatal overdoses, the harm reduction program Prevention Point Philadelphia, partnering with a local physician, has begun to help distribute naloxone, a medication that if used soon enough during an overdose can save the victim's life.

Naloxone distribution is a type of program known as "harm reduction," the idea of which is that since we know some people are going to use drugs regardless of how we fight them, there are things that can be done to help them save their lives and the lives of others -- even before they stop using drugs, for that matter even if they never stop using drugs. Needle exchange programs are another example of harm reduction at work.

The drug czar's office reacted to the PPP venture with criticism. If heroin users have a chance of surviving an overdose, the reasoning went, it is "disinhibiting" to the objective of getting addicts to just stop using the stuff. "We don't want to send the message out that there is a safe way to use heroin," an ONDCP spokesperson said. But "dead addicts don't recover," as the common mantra in the harm reduction field goes.

While the drug czar's position is dead wrong about this -- deadly wrong, in fact -- the comment seems a fairly truthful explanation of the horrible way that many drug warriors think. It is a direct corollary of the spokesperson's comment that it is better to have people who could be saved instead die, in order to dissuade others from using drugs -- better to make sure that drugs kill -- so that everyone will be sure that drugs do kill. But the dead from overdoses are definitely (and permanently) dead, whereas those who, through the withholding of livesaving assistance to some, are thereby saved from death through their own choices, may or may not exist.

Those who oppose harm reduction are in effect supporting "harm intensification" instead -- a deliberate attempt through policy to increase the dangers of drugs -- at a cost of lives, and in my view of morality too.

But that is what prohibition is truly about, harm intensification on a global scale. Hence the need for legalization instead -- so morally defunct ideas like those expressed this week by the drug czar's office can be laid to rest and their ghastly consequences finally be made to cease.

(This memorial piece for a great pioneer in addiction treatment was written and distributed by his friend and colleague, Dr. Robert Newman.)

Dr. Vincent Dole (an internist) and his late wife, Marie Nyswander, MD (a psychiatrist), began their collaborative research with methadone with a handful of long-term heroin-dependent individuals in 1964. They did so in the face of overt threats of harsh criminal and civil action by federal narcotics agents. Their courageous, pioneering work demonstrated that methadone maintenance is a medical treatment of unparalleled effectiveness -- a superlative description that is as applicable today as it was four decades ago. As a result, well over three-quarters of a million people throughout the world are able to lead healthy, productive, self-fulfilling lives - over 200,000 in the United States, an estimated 530,000 in Western Europe, and many tens of thousands more in Eastern Europe, Middle East, Central Asia, Far East, Australia and New Zealand.

After the remarkable transformation they observed in their first few patients, Dr. Dole and Dr. Nyswander went on to provide direct supervision of the first methadone maintenance treatment program at Beth Israel Medical Center in New York. In so doing they demonstrated that it was possible to replicate on a large scale the therapeutic success they achieved in the small, controlled, research environment of the Rockefeller Institute (now Rockefeller University). Dr. Dole was also responsible in the early 1970s for convincing the New York City Department of Corrections (at the time headed by Commissioner Ben Malcolm) that detoxification of heroin-dependent inmates in the city's main detention facility at Rikers Island was imperative to save lives and lessen suffering (there had been a wave of suicides at the time that had been attributed to severe opiate withdrawal). The detoxification program continues to this day, and has become a model for enlightened corrections officials in other countries.

Dr. Dole and Dr. Nyswander's contributions, however, transcend the life-saving clinical impact on patients and the enormous associated benefits to the community as a whole. They had prescience to hypothesize, years before the discovery of the morphine-like endorphine system in the human body, that addiction is a metabolic disorder, a disease, and one that can and must be treated like any other chronic illness. What was at the time brilliant insight on their part is today almost universally accepted by scientists and clinicians alike, and remains the foundation upon which all rational policies and practices in the field rest.

In his mid-80s Dr. Dole traveled to Hamburg to be present at the naming ceremony of the Marie Nyswander Street; in less than ten years Germany moved from methadone being illegal to having over 60,000 patients in treatment! His efforts during recent years were devoted to fighting the stigma that, tragically, remains so widespread against the illness of addiction, the patients and the treatment.