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.

The surgery was a success, but…

1368951062alarabalaanPublic health workers are declaring their harm reduction approach a success:

Harm reduction — not a war on drugs — has reduced illicit drug use and improved public safety in what was once Ground Zero for an HIV and overdose epidemic that cost many lives, says a 15-year study of drug use in Vancouver’s impoverished Downtown Eastside.

The report by the B.C. Centre for Excellence in HIV/AIDS found that from 1996 to 2011, fewer people were using drugs and, of those who were, fewer were injecting drugs, said Dr. Thomas Kerr, co-author of the report and co-director of the centre’s Urban Health Research Initiative.

“A public health emergency was declared here because we saw the highest rates of HIV infection ever seen outside of sub-Saharan Africa — in this community. At the same time, the community was being levelled by an overdose epidemic,” Kerr said after presenting his findings to members of the group affected at a community centre in the heart of the neighbourhood.

Vancouver took a public health approach to the crisis, opening the country’s first supervised injection site in 2003, and Kerr said the statistics show that approach was successful.

Kerr goes on to pull the scientific evidence card, casting critics as stupid, unethical and indifferent to death:

“We have a federal government that ignores science in favour of ideology, and people are sick and dying as a result,” Kerr said.

“When we’re dealing with matters such as life and death, I think we’re obligated to base our decisions on the best available scientific evidence. I think it’s unethical to do otherwise.”

However:

There was some disappointing news for health officials in the study.

There has been only a slight drop in mortality rates among the city’s illicit drug users, who have a death rate eight times higher than the general population.

What’s that saying? The surgery was a success, but the patient died.

Now, I’m not saying that law enforcement is a better approach and I’m not saying that reduced disease and crime are unimportant, they are important. However, one of my concerns about public health approaches is that they are often designed to serve the public rather than the individual. When the death rate is only slightly affected, and addicts are still using and homeless, who’s best served by these outcomes of reduced disease and crime?

Harm reduction is not enough. In and of itself, it is not bad.

It’s just bad when the public and professionals declare victory while addicts continue to suffer terrible quality of life.

How much money was spent to achieve these outcomes? How else might that money have been spent?

Why not recovery?

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.

 

 

Two stories on methadone

English: Methadone structure, animation

First,

DEATHS among drug users have hit a record high in Scotland, increasing by a fifth in 2011, the latest government figures reveal.

Last year 584 people died from drug use, which means that drugs now account for one in every 100 deaths in Scotland.

The heroin substitute, methadone, was at the heart of the increase, with almost half of the drugs-related deaths involving the prescription drug.

Second,

How I Learned to Stop Worrying and Love Methadone

Just like ex-junkie Russell Brand, I used to believe that “maintenance” was as bad—if not worse—than active addiction. Here’s how I came to understand how fatally wrong I was.

I have no quarrel with any addict receiving methadone maintenance, IF they’ve been provided with accurate information and quality drug-free treatment.

I wish that, rather than describing methadone as, “the most effective treatment for opioid addiction,” they would be more specific about what they mean by effective:

…study after study shows that when methadone prescribing increases, addict deaths drop. It is superior to abstinence-only treatment in terms of fighting HIV and overdoses, and many studies find it superior in cutting crime.

Those things are important, but methadone is not the only way to achieve those goals and they’re not the only things that are important.

Of course, as we’ve pointed out many times, there is one group of opiate addicts that are not treated with opiate maintenance. Doctors are not treated with opiate maintenance and they have terrific outcomes.

Are we really denying addicted doctors “the most effective treatment for opioid addiction”?

Of course not. We’ve decided that, for them, we’re going to aim a little higher than reducing overdose risk, crime and HIV.

Harsh enforcement has failed

drug policy by mmcrae01

This Foreign Policy article provides a concise snapshot of the failure of the “harsh enforcement” approach to drug policy:

As a domestic policy, a harsh enforcement approach has done little to control drug use, but has done a lot to lock up a growing portion of the U.S. population. Cocaine and opiate prices are about half their 1990 levels in in America today. And 16 percent of American adults have tried cocaine — that’s about four times higher than any other surveyed country in a list that includes Mexico, Colombia, Nigeria, France, and Germany. And while criminalization has a limited impact on price and use, it has a significant impact on crime rates. Forty percent of drug arrests in the United States are for the simple possession of marijuana. Nearly half a million people are behind bars in the United States for a drug offense — that’s more than ten times the figure in 1980.

It’s easy to write with certainty when you are vague. It’s also easier when you are only addressing a narrow set of values:

Conversely, the Global Commission on Drug Policy report compiled evidence suggesting that approaches based on treatment rather than punishment were far more effective in reducing consumption, HIV prevalence, and crime rates among users. For example, Britain and Germany, both of which long ago adopted harm reduction strategies for people injecting drugs — programs that include needle exchange programs and medication — see HIV prevalence among people who inject drugs below 5 percent. The United States and Portugal, by contrast, where such strategies were introduced later or only partially, see HIV prevalence among a similar community at above 15 percent.

“Reduced consumption” is a good thing, I suppose. But, is that a good indicator of the welfare of addicts? I’m not so sure.

Based on my knowledge of the UK system, would I rather be a heroin addict in the US or the UK? Easy call—the US recovery model or UK harm reduction model—recovery.

The US’s incarceration rates for drug offenses are terrible, indecent and stupid. However, I’m not certain that a system that believes addicts can’t recover, offers only methadone even though patients express a preference for abstinent recovery is better even if it does reduce crime and disease. Does this show more restraint in the exercise of social control? Not clear to me.

The sands are shifting in both the UK and the US. It’d be nice if we could stop having these either/or discussions and consider entertaining a both/and conversation.