Worth Every Penny?

Compare this legitimate injection kit obtained...
Compare this legitimate injection kit obtained from a needle-exchange program to the user-compiled one above. (Photo credit: Wikipedia)

Preventing HIV is a very good thing.

The Atlantic has a post about the role of needle exchanges in preventing HIV. It makes a pretty compelling case that needle exchanges reduce HIV infection rates among injection drug users. I don’t doubt this. And, provided it serves as an engagement point for recovery, I have no objection to needle exchanges.

However, there are a few things that bug me about these stories.

First, there’s not a single mention of addiction treatment or recovery. Not one word.

Second, one would walk away from this article assuming that injection drug users make up a huge portion of HIV infections. Not true. CDC numbers suggest that, nationally, injection drug users make up around 8% of all new infections.

Third, there’s not a single mention of overdose. The article focuses on LA as a success story, and they have been successful in reducing infections. In 2005, they had 83 new infections among injection drug users. How many overdose deaths? 508. Not a single mention of overdose. We’re busy bragging about the success of the surgery while the patient has died.

Fourth, while I don’t doubt that needle exchanges reduce infection rates, what else also reduces infection rates? We don’t really know. The only research that’s done on the matter focuses on methadone.

Finally, the story was prompted by a new report about infections in Washington DC. The writer says:

According to the department’s research, the repeal of a decade-long ban that prevented D.C. from using local funding for clean needle exchanges led to a major reduction of needle-caused HIV infections. The city is now reporting an astonishing 80 percent decrease in the number of newly diagnosed HIV cases where the reported mode of transmission was injection drug use. In 2007, the year Congress lifted the 1998 ban on D.C.’s needle exchanges, there were 149 cases of needle-caused HIV. In 2011, there were just 30.

That’s pretty great, right? Fewer infections is a great thing. However there’s one very big problem with the way this story frames the data. In 2007, injection drug users made up 29% of new infections. In 2011, they made up 27% of new infections. The big story is that new HIV infections dropped dramatically. Injection drug users are a slightly smaller portion of new infections.

It took me two minutes of googling and reading his own source documents to find this data. Why do so many of these stories fail to provide this context? Why didn’t a reporter spend a couple minutes with a search engine before submitting this? There are lots of stories like this every year. I don’t understand it.

“Giving Drug Addicts Free Clean Needles Is Worth Every Penny” is a good headline, but what’s the rest of the story? There’s more to HIV and addiction than an accounting exercise.

Number one cause of death among the homeless

Homeless man in Anchorage, Alaska
Homeless man in Anchorage, Alaska (Photo credit: Wikipedia)

 

Wow.

 

Overdoses of drugs, particularly prescription painkillers and heroin, have overtaken AIDS to become the leading cause of death of homeless adults, according to a study of homeless residents of Boston released on Monday.

The finding came from a five-year study of homeless adults who received treatment from the Boston Health Care for the Homeless Program, though its broad conclusions apply to homeless populations in many urban parts of the United States, the study’s author and homeless advocates said.

The tripling in the rate of death by drug overdose reflects an overall rise in pain-killer abuse, said Dr. Travis Baggett of Massachusetts General Hospital, the lead author of the study, to be published next month in the journal JAMA Internal Medicine.

“This trend is happening across the country, in non-homeless populations too,” Baggett said. “Homeless people tend to experience in a magnified way the health issues that are going on the general population.”

The study, which tracked 28,033 homeless adults from 2003 through 2008, found that of the 17 percent who died during the study period died of drug overdoses while 6 percent died of causes related to HIV, the virus that causes AIDS.

 

 

More on methadone

 

Points is publishing a series on methadone and offers a case for methadone without resorting to describing it as “the most effective treatment for opiate addiction.”

It’s a pretty fair piece. I had only one quibble with the facts of the story. This is unusual and very welcome. However, the author and I disagree starkly about the context and meaning of those facts. (As I pointed out last week, we seem to lower the bar for these addicts.)

It opens with this statement:

…there is one treatment that offers real hope.

Okay hope is good. Hope for what?

Reduced Crime

One of methadone’s biggest strengths is reducing this criminal behavior. The vast majority of research shows a marked decrease in crime following methadone treatment.  One particularly large study, involving over 600 patients, showed a 70.8 percent decline in “crime days” – a 24 hour period in which an individual commits one or more crimes – during the first 4 months of methadone maintenance treatment.

Reduced HIV Transmission

The post erroneously reports that, “More than 36% of new A.I.D.S. cases are attributed to intravenous drug abuse.” The report they cite actually says:

Since the epidemic began, injection drug use has directly and indirectly accounted for more than one-third (36%) of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 42,156 new cases of AIDS reported in 2000, 11,635 (28%) were IDU-associated.

These numbers includes people whose only exposure was IDU and people who reported possible IDU transmission AND male-to-male sexual transmission. A more recent report puts these new case transmission numbers significantly lower. Among men, IDU transmission was reported in 7% of cases. (IDU and male-to-male exposure was reported in another 4% of new male cases.) Among women, IDU transmission was reported in 14% of new cases. The total for all 3 groups would be 5594 new IDU-associated cases.

At any rate, the argument is as follows:

Even though methadone does not stop some addicts from continuing IV drug abuse, it reduces that needle share rate to 1/5.   In addition to reducing H.I.V. infections, methadone reduces prostitution by addicts, another major cause of new infections.

Reduced Drug Use

When measuring whether a treatment is effective or not, the primary concern is whether addicts stop or use fewer drugs than before they started treatment.  Methadone succeeds in this regard.  Drug use declines dramatically in those who undergo treatment, and it continues to decline as addicts spend more time in treatment.  Relatively new research shows that addicts who receive higher doses (measured as 80-100 milligrams) use even fewer opiates than the traditional treatment population, who are usually maintained on a sub-optimal dose.

A Couple of Qualifiers

First:

However, the majority of patients drop out within a year.

Second:

Nearly 40 percent of patients drop out of methadone programs during their first year of treatment due to incarceration.

What about Abstinence?

Abstinence is dismissed as absolutist and simplistic.

Defining success is of critical importance when assessing any treatment’s effectiveness.  The simplistic view looks at whether a treatment stops an addict from using their drug of choice.  This absolutist approach is problematic for a number of reasons.