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?

The benefits of harm reduction are not as obvious as they seem

Warning: This Area Contains Tobacco Smoke
Warning: This Area Contains Tobacco Smoke (Photo credit: tbone_sandwich)

Theodore Dalrymple points out the inconsistency in the British Medical Journal’s vigorous advocacy for harm reduction where heroin is concerned and its squeamishness with harm reduction for nicotine. He pulls a passage from BMJ and inserts comments:

What, then, does the BMJ, so much in favour of harm reduction for heroin addicts, say about harm reduction for smokers?

A broad perspective suggests potential problems [from a public health perspective].

Firstly, the new nicotine containing products are not intuitively appealing; smokers will need to be persuaded of their benefits. For public health there is a key benefit: it is easier to use them than to   quit. Here I interject that the same is true of the methadone or other substitute for heroin. But for most smokers quitting is the best option and should be presented as achievable and attractive.

   So rolling out harm reduction puts public health in the contradictory position of having to emphasise both the difficulties and attractions of quitting. Why should harm reduction for heroin addiction be any different, one might ask? A related danger is that children will pick up on this apparent confusion. While previous generations were told simply that tobacco is bad, new ones would learn that nicotine is acceptable – just be careful how you access it. This is precisely the burden of public health “education” with regard to heroin and other drug addiction. Moreover, promotion of harm reduction might reduce the perceived “cost” of uptake. Would not the same effect apply to the medical treatment of drug addiction, to say nothing of the provision of free needles? Finally, the fact that e-cigarettes deliberately mimic conventional ones (even to emitting fake smoke) may result in the inadvertent modelling of smoking. Would not the prescription of injectable methadone not do the same? More broadly, the media, which in the UK have become a reliable supporter of comprehensive control measures, might also struggle with this more complex position. How much media effort, one is inclined to ask, ‘reliably’ goes into supporting ‘comprehensive control measures’ with regard to illicit drugs? Thus the benefits of harm reduction are not as obvious as they seem.

The article goes on to criticise harm reduction in tobacco because of the obvious, if not entirely consistent, commercial interests that the tobacco and pharmaceutical industries have in it.

Dead space is the part of the syringe where fluid is retained once the plunger is fully depressed. High-dead-space syringes retain fluid both in the syringe itself and in the needle; low-dead-space syringes expel all the fluid in the syringe, retaining only a small amount of fluid. (In low-dead-space syringes, the needle is not detachable.)

In experiments that mimicked drug injections, the high-dead-space syringes retained 1,000 times as many microliters of blood, even after rinsing. For people carrying HIV with viral loads between one million copies and 2,000 copies per milliliter, the capacious syringes could carry multiple copies of HIV, “whereas,” William A. Zule and his coauthors write, “low-dead-space syringes would retain even a single copy only a fraction of the time.”

What’s interesting here, is that needle exchange advocates have been so busy arguing that they are the obvious answer to injection disease transmission on pragmatic and moral grounds, while insisting that there are no social costs (ignoring the fact that needle sharing persists among exchange users, discarded syringes are a problem, they often ignore treatment access problems and that they make convey despair to addicts and communities), that they seem to have never stopped to ask if we could make syringes safer.

These low-dead-space syringes in universal use might be much more effective than needle exchanges and prevent transmissions through accidental pokes. If so, will they follow the evidence?

Dead addicts don’t recover, but…

Naloxone (1)
Naloxone (Photo credit: intropin)

This has gotten a lot of press. There’s naloxone distribution doubt this will reduce overdose deaths. However, some pretty important questions remain:

  • What happens after the overdose?
  • What services/interventions might have prevented the overdose in the first place?

The article references placing defibrillators in public places. What happens after someone is saved by one of those defibrillators? An ambulance comes and takes them to receive treatment. (Often treatment that costs tens of thousands of dollars.)

0 = Number of times the word “treatment/treat/treatable” appears in the article

0 = Number of times the word “recovery/recover” appears in the article

So … dead addict don’t recover, but why do we seem to care so little about treating what nearly killed the patient?

The political left and prohibition

"Legalization Now" Banner At The May...
“Legalization Now” Banner At The May Day Immigration Rights Rally (Washington, DC) (Photo credit: takomabibelot)

Andrew Sullivan picks up on Jack Meserve’s discussion of the political left and prohibition:

Meserve:

Think of a few of the currently illegal vices: recreational drug use, gambling, prostitution. With some exceptions, the left has been in favor of legalization or decriminalization of these activities. Now think of legal vices: gluttony, cigarette smoking, alcohol use. On these habits, we’ve supported bans, onerous restrictions on place and time of consumption, and increasingly aggressive fines and taxes. There seems very little consistency between these positions, and few have even attempted justifying the differences. Progressives have been guilty of letting our temperament rather than our reason guide the policies; bans on activities like drug use are seen as naive or old-fashioned, but legal vices like cigarette smoking are public-health or collective-action problems to be solved through brute government action.

Then, Sullivan offers some reader reactions to Meserve. Here are just a couple:

…legalization isn’t being pursued as a public health issue.  It’s being pursued to make sure people don’t face fines, criminal charges, arrest, or jail time for using a substance that is less harmful and addictive than other legal substances.  Any public health aspects come into play when you discuss how pot would be regulated ONCE it is legal.  But Meserve doesn’t discuss or raise any public comments about what happens post legalization in the piece.

another:

Why is the pot legalization initiative on the ballot in Washington when legalization has failed to qualify so many times before, despite our alleged libertinism?  Well, this one contains a 25% excise tax dedicated to substance abuse prevention and healthcare in general, a state-run store regime was added, age limits put in, and specific concentrations of THC in the bloodstream for DUI were defined.  These things were absent in prior initiatives, meaning that had they qualified and passed, anyone could have set up shop across from a kindergarten to sell. It’s almost instead of us being a bunch of stoned hippies just out for a good time, we wanted to make sure that this vice was legalized in the most thoughtful, responsible way possible, while also making provisions for ameliorating possible social harms caused by legalization.  That’s left-wing social engineering at its best.

Towards a smarter drugs policy

The new issue of the Lancet focuses on drug policy. One piece offers key points for formulating policy:

  • Drug policy should aim to promote the public good by improving individual and public health, neighbourhood safety, and community and family cohesion, and by reducing crime.
  • The effectiveness of most drug supply control policies is unknown because little assessment has been done, and very little evidence exists for the effectiveness of alternative development programmes in source countries.
  • Supply controls can result in higher drug prices, which can reduce drug initiation and use but these changes can be difficult to maintain.
  • Wide-scale arrests and imprisonments have restricted effectiveness, but drug testing of individuals under criminal justice supervision, accompanied by specific, immediate, and brief sentences (eg, overnight), produce substantial reductions in drug use and offending.
  • Prescription regimens minimise but do not eliminate non-medical use of psychoactive prescription drugs. Prescription monitoring systems can reduce inappropriate prescribing.
  • Screening and brief intervention programmes have, on average, only small effects, but can be widely applied and are probably cost-effective.
  • The collective value of school, family, and community prevention programmes is appraised differently by different stakeholders.
  • The provision of opiate substitution therapy for addicted individuals has strong evidence of effectiveness, although poor quality of provision reduces benefit. Peer-based self-help organisations are strongly championed and widely available, but have been poorly researched until the past two decades.
  • Health and social services for drug users covering a range of treatments, including needle and syringe exchange programmes, improve drug users’ health and benefit the broader community by reducing transmission of and mortality due to infectious disease.

It’s good stuff. I particularly like its willingness to give credit where credit is due. For example, supply control can help but the benefits are often unstable and have a lot of unintended consequences. I also like the affirmation of the diversity of perspectives on the benefits of policies.

Not surprisingly, the only thing that grates me is the pushing of opiate substitution. (They weigh in a little harder in the body of the paper.) I’ve got no objection to saying it should be part of the service menu, but when they argue that it’s got the strongest evidence base, shouldn’t we ask why that is? What drives the research agenda? Who decides what to research? Who decides what outcomes are important? What are their assumptions? What are their values? Who benefits from the research agenda?

I don’t fear substitution being part of the service menu, but I fear it becoming the standard of care. I fear it setting the bar unacceptably low and creating a reflexive loop that reinforces the assumptions of researchers and treatment providers and traps addicts in a state of permanent disability and dependence upon treatment providers who believe they’re incapable of recovery.

Would the researchers and doctors recommend this treatment to a loved one? To a colleague? (Hint, they definitely don’t recommend it to colleagues. And, it’s not too expensive for the rest of us.)