If we want to help drug users, prescribing heroin should be part of the treatment.
IN OCTOBER 1987, while travelling overseas to learn about HIV and injecting drug use, I spent an evening in a ''shooting gallery'' in Brooklyn, New York City. I watched for hours as four Hispanic men and women injected ''speedballs'' of heroin mixed with cocaine. It was a life-changing experience. We were in the basement of a dilapidated, abandoned tenement building. There was no electricity. Cars parked in the street were propped up on bricks with smashed windscreens. This was urban squalor unimaginable in Australia.
Carrying injecting equipment in the streets was far too risky, especially for minorities. Renting a ''shooting gallery'' for a few hours reduced the risk of being bothered by the police. Needles and syringes were supplied, but the catch was they had already been used by many other people.
I watched as the four injected with little regard for hygiene. Thinking of comparable situations in Australia, I wondered why these American injectors had such little concern for their future. Then I realised that a decent education, proper housing or a reasonable job would have been impossible dreams. Hope for a better life for their children or grandchildren? Forget it. By contrast, the revolving door of prison would have been an all too familiar reality. That was when I first became interested in inequality and illicit drug use.
Inequality has been a constant theme in illicit drugs. Australia's first laws on drugs in the late 19th century banned the smoking of opium in South Australia, Victoria and NSW. The only opium smokers then were the Chinese working in the goldfields.
American missionaries in the 19th century witnessed the appalling misery resulting from the British forcing opium on to the Chinese. China tried to stop the then more powerful British but lost both opium wars. The experience helped prompt the US to convene the International Opium Commission in Shanghai in 1909, setting the scene for global drug prohibition.
Sixty years later, then US president Richard Nixon declared a war against drugs. As Nixon aide John Ehrlichman said: ''Look, we understood we couldn't make it illegal to be young or poor or black in the United States, but we could criminalise their common pleasure. We understood that drugs were not the health problem we were making them out to be, but it was such a perfect issue for the Nixon White House that we couldn't resist it.''
Effective political strategy turned out to be a public policy disaster. While politicians in many countries competed to have the toughest policies, drug production and consumption soared and deaths, disease, crime and corruption steadily increased. The six deaths from drug overdose in Australia in 1964 rose to more than 1100 in 1999.
Multiple scientific studies suggest that prescribing heroin to the most severely dependent heroin injectors, who have not benefited from all other treatments and punishments, has real benefits for the individuals and the community.
In 1997, a large Swiss study concluded that for this minority of entrenched heroin users who had never benefited from repeated episodes of diverse treatments or prison, giving them heroin as part of their treatment provided huge benefits, with few side effects. Their physical and mental health improved considerably. Consumption of street drugs decreased. Crime, measured three different ways, decreased substantially. The treatment was much more expensive than the standard methadone treatment, but for every Swiss franc the program cost, there were gains of two Swiss francs.
Rigorous scientific studies were then also conducted in the Netherlands, Spain, Germany and Canada. All showed similar results. All were published in reputable journals. This month, the results of a British study were released. Again, the results were similar to the previous studies. In each, heroin was self-administered under stringent supervision. Abundant, high-quality psychological and social support was provided.
After a decade of heroin-assisted treatment in Switzerland, the treatment is still only provided to a steady 5 per cent of those seeking help.
This small minority of severely dependent drug users is so important because they account for a disproportionate share of the drug-related crime.
In a national referendum last year in Switzerland, 68 per cent supported retaining heroin-assisted treatment as a last resort. The Netherlands now also provides the treatment. Earlier this year, 63 per cent of members of the German parliament voted to allow heroin-assisted treatment. All major political parties in Denmark recently supported the treatment.
Australian researchers in the 1990s investigated heroin-assisted treatment for more than five years. In July 1997, health and police ministers voted six to three to support a trial but prime minister John Howard aborted the process, arguing that it would ''send the wrong message''.
Twelve years later, the message from the scientific evidence is clear: if we want to help drug users, their families and communities, then prescribing heroin should be part of the package we provide.
But we should also try to reduce the extent of inequality in our community. There is increasing evidence that more unequal communities have worse public health outcomes, with higher rates of illicit drug use, mental illness, obesity and crime. At a time when our taxation system is under review, reducing inequality is the debate that Australia has to have.
We don't need a debate about heroin-assisted treatment. We should be providing this now to the small minority with very severe problems who have not benefited from repeated episodes of other treatments.
Alex Wodak is director of the Alcohol and Drug Service at St Vincent's Hospital, Sydney. He is speaking at the ''Drugs in Hard Times'' conference on October 1 in Melbourne.
September 24, 2009
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