Pubdate: Mon, 4 Jan 2010
Source: Nation, The (US)
Copyright: 2010 The Nation
Author: Beth Schwartzapfel


Policy wonks and deficit hawks weren't the only ones paying attention 
when President Obama signed the Fiscal Year 2010 Consolidated 
Appropriations Act last week. HIV activists, public health experts 
and communities of drug users celebrated--not for what's in the 
appropriations bill, but for what's not in it: a ban on federal 
funding for needle exchange programs, which has appeared in the 
federal budget every year since 1988.

After two decades, this change is a historic achievement. Obama had 
already missed one opportunity to lift the ban, neglecting to pull it 
out of his budget in May. Still, that same month former Seattle chief 
of police Gil Kerlikowske was sworn in as the director of national 
drug control policy, calling for a new common-sense approach to drug 
addiction. When the drug czar calls for an end to the war on drugs, 
it's clearly the start of a new era.

Unlike during the Clinton administration, when there was only mixed 
support for needle exchange--in 1998, drug czar Barry McCaffrey 
convinced Bill Clinton to renege on his stated intention to lift the 
ban--all of the top brass in the Obama administration are on record 
in favor. Kerlikowske supported Seattle's program of exchanging 
needles. FDA Commissioner Margaret Hamburg and CDC Director Tom 
Frieden both served as New York City Health Commissioner, and both 
used that position to actively promote needle exchange. Still, drug 
policy watchers agreed that the president didn't want to force the 
question of needle exchange on members of Congress. The White House 
was "concerned about making sure that when Congress deals with the 
issue, that they can win it," says Harm Reduction Coalition Policy 
Director Daniel Raymond.

That left it up to members of Congress to lift the ban themselves, 
and in November, the House did just that--sort of. In an attempt to 
broaden political support for lifting the ban, Congressman David 
Obey, a Democrat from Wisconsin and chair of the committee whose 
conference report contains the language, introduced a "thousand-foot 
rule," which would have maintained the ban on funding for exchanges 
within 1,000 feet of a school, park, library, college or video 
arcade. Obey himself acknowledged at the time that the thousand-foot 
rule was "unworkable"--since it would simply be a ban by another 
name, especially in densely settled urban areas. He said, however, 
that he hoped the language could be changed when the House and Senate 
versions of the bill went to conference committee. That's precisely 
what happened last week.

The new provision prohibits federal funding of needle exchanges "in 
any location that has been determined by the local public health or 
local law enforcement authorities to be inappropriate for such 
distribution." But because needle exchanges "have been operating for 
over twenty years with community support and buy-in already," says 
Jirair Ratevosian, deputy director of public policy for amfAR, the 
Foundation for AIDS Research, this new language essentially ends the 
ban. Exchanges "already have support from law enforcement agencies; 
they already have support from public health groups, from local 
planning committees," Ratevosian noted.

In addition to the much-needed dollars that will start flowing to 
needle exchanges, lifting the ban is also of huge symbolic importance 
to a presidency whose commitment to a public health approach to drug 
addiction has at times amounted to more talk than substance. But 
needle exchange is only one intervention among many that have come to 
be known as "harm reduction"--taken together, this approach to 
addiction is pragmatic rather than punitive. Instead of attempting to 
eliminate addiction altogether, it seeks to mitigate the harms--HIV, 
hepatitis C, overdose and criminality, among others--that addiction 
can cause. Many harm reduction programs have been studied extensively 
and are widely understood to be effective but continue to be stymied 
by politics, even under Obama and Kerlikowske. That, until recently, 
was the fate of needle exchange itself.

Safe injection facilities, for example, take needle exchange to the 
next level by offering users a safe place to inject drugs under 
medical supervision. There are some sixty-five safe-injection 
facilities in forty cities around the world (none in the United 
States), and many years of research in those places have demonstrated 
that SIFs reduce overdose deaths and risky behaviors and lead to 
other positive outcomes. In 2004, while he was Seattle chief of 
police, Kerlikowske paid a visit to the only SIF in North America, in 
Vancouver, and wrote a cautious but open-minded memo in which he said 
that it would be "worthwhile to continue to monitor the Vancouver 
drug experience."

Could such a program take shape in this country? Several harm 
reduction activists in New York City say that it already has, under 
the radar: much the same way as groups of drug users organized 
informal needle exchanges in the '80s, long before they were legal, 
groups of savvy users have become lay EMTs and have stocked what 
might otherwise be considered "crack houses" with clean needles and 
medications to reverse the effects of overdose. In May, a coalition 
of harm reduction organizations in New York City sponsored a 
conference at John Jay College of Criminal Justice to explore the 
possibility of opening a legal safe-injection facility in New York. 
San Francisco's health department sponsored a similar conference in 
2007. Given that state legislation to legalize safe- injection 
facilities is not likely to be forthcoming anytime soon, legal 
scholars who study the issue believe it would be possible to 
establish some legal basis for opening such a facility in the United 
States if a state or local health department were to issue a 
regulation authorizing it for public health reasons. Or an academic 
medical center could set up a safe-injection facility as a research 
project, which would insulate it from certain legal problems.

While research suggests that funded needle exchanges will cut down on 
deaths due to drug-related infectious disease, neither AIDS nor 
hepatitis is the leading cause of death among drug users. In fact, 
overdose has that distinction--and opiate overdoses can be reversed. 
Inject Narcan--i.e., naloxone--into the muscle of someone who is 
dying of a heroin or OxyContin overdose, and within seconds he is 
awake and very much alive. Narcan has been used for decades in 
ambulances and emergency rooms to reverse opiate overdose. If those 
with severe allergies can carry Epi-pens with them, advocates ask, 
why can't drug users themselves carry Narcan? Legally they can, with 
a prescription from a doctor. And yet, prescriptions are not nearly 
as common as they should be.

In more than fifty programs in seventeen states, doctors prescribe 
Narcan to drug users in conjunction with education about overdose. 
Several states, including New York, have passed Good Samaritan laws 
that provide legal immunity to physicians who prescribe Narcan and to 
lay people who administer it in good faith. But the majority of 
states lack legislation on the issue, so a person administering 
naloxone to someone else may be vulnerable to prosecution should 
something go wrong. Still, an overdose-prevention working group 
chaired by the Substance Abuse and Mental Health Services 
Administration is looking at releasing best practices on overdose 
prevention, and states could begin to look there for legislative 
guidance. Dr. Sharon Stancliff, medical director of the Harm 
Reduction Coalition--who herself prescribes Narcan--is a member of 
the group. "I actually have a lot of hope that Narcan will be widely 
adopted in the near future," she says.

The same cannot be said for heroin maintenance, another public health 
approach to addiction backed by years of research. At least a 
half-dozen countries, including the Netherlands, Switzerland, and the 
UK, allow prescription of pharmaceutical heroin, known as 
diamorphine, to users who have failed to improve using all other 
available treatment options. Diamorphine is prescribed to "people who 
have been through methadone, been through jail, been through drug 
free [treatment facilities], been through the whole gamut of things, 
and for whom nothing was working," says Ethan Nadelmann, the 
executive director of the Drug Policy Alliance (DPA), which worked in 
partnership with a group in Canada to set up that country's first 
clinical trial of heroin maintenance. (The trial enrolled 250 users 
in two cities; early results show a significant reduction in 
participants' criminal involvement and an increase in their health.) 
As recently as this year, both the German and Danish parliaments 
voted to allow prescription of heroin to those who have not responded 
to other treatments. Nadelmann is hopeful that a clinical trial 
similar to Canada's can be set up in the US in the coming years. but 
Columbia University associate professor of clinical neuroscience Carl 
Hart is not so sanguine. "People have been brainwashed [into 
thinking], 'These awful drugs that are causing so many 
problems--you're going to give it as a medication?'" he says, citing 
deepseated public fears.

That precisely describes methadone. Methadone and heroin operate in 
identical ways on opiate receptors in the brain. They are both "full 
agonists," meaning they fill up opiate receptors in such a way as to 
make the user high. The main difference between heroin and methadone 
is not their chemical composition but their legality. The daily 
hustle for heroin often forces users into other illegal activity, 
like petty drug dealing, prostitution and burglary, to support their 
habit, and creates an expensive, unproductive revolving door between 
prison and the street. Methadone, covered by insurance, frees people 
from this cycle. Because methadone is administered by physicians, it 
can be dispensed in amounts precisely calibrated to someone's 
addiction to make that person feel "normal," rather than high, and 
eliminates the craving and withdrawal symptoms that drive people to 
use. Heroin, sold on the black market, is "cut" with adulterants; at 
best, the cut (like baby powder or quinine) is itself harmless but 
causes wide variation in the strength of the heroin--which makes it 
impossible for a user to know exactly how much he is using.

Still, if a person takes more than her prescribed dose of methadone, 
she can get a high quite similar to heroin's. And when used in 
conjunction with other drugs, or when diverted--which is to say, sold 
on the street--methadone can cause overdose, just like heroin. This 
is why methadone is so tightly regulated. Unlike most other 
medications (including OxyContin, also a full agonist), there are 
almost no circumstances under which a physician can prescribe 
methadone for home use. Users enrolled in methadone programs must be 
physically present at the clinic each morning for their dose of methadone.

Over the years, a cottage industry of ancillary services has grown up 
around methadone clinics. Everything from talk therapy to medical 
care to Narcotics Anonymous meetings to group picnics and bowling 
excursions has come to be understood as a necessary component of the 
treatment of such a psychosocially complicated problem as addiction.

But part of the public health approach touted by Kerlikowske and his 
boss in the White House is to treat addiction like any other chronic 
illness. Scientists have been looking for years for a gene or a pill 
that can treat the disease without all the messy and unpredictable 
psychological baggage that the meetings and talk therapy are designed 
to address. The closest thing we have right now to a litmus test for 
whether such a thing is even possible is a medication called 
buprenorphine. "Bup," as it's known (pronounced byoop), is a "partial 
agonist," which means that, unlike methadone or heroin, it can only 
make a person so high. What's more, the formulation available in the 
United States is mixed with naloxone--the very same drug used to 
reverse overdose--so that someone who tries to abuse the drug will go 
into withdrawal. It's not foolproof--it is possible to abuse bup--but 
because it's much safer than methadone, bup eliminates methadone 
clinics' primary reason for existence: safety. So the FDA has 
cautiously opened the door to allowing physicians in to prescribe bup 
like any other medication, for patients to take at home. When the 
drug was approved by the FDA in 2002, it became the only opiate 
addiction treatment that may be prescribed outside of the tightly 
policed boundaries of the methadone clinic. A small pill that 
dissolves under the tongue, bup in the first few days is taken in 
increasingly higher doses each morning until the user feels "normal," 
but not high.

What will happen when users can sidestep the counseling and the 
clinics, and just take the "anti-addiction pill" that their local 
primary care doc prescribes along with their blood pressure 
medication? Bup could be providing preliminary answers to that 
question. But it's not, because it is still tightly regulated in a 
way that limits its integration into mainstream medical practice.

Nurse practitioners and physician assistants, who do a lot of "on the 
ground" prescribing, are not allowed to prescribe bup. Rather than 
encouraging the mainstreaming of addiction treatment, the FDA 
requires that physicians demonstrate expertise in addiction and 
attend a day-long training before they may prescribe bup (as of this 
writing, there were no in-person trainings scheduled anywhere in the 
country, though online trainings are available). And even then, a 
single practice--no matter how many physicians are on staff--is 
limited to a maximum of thirty patients on bup at a time in the first 
year, 100 in the second year.

Which is to say that instead of treating addiction like any other 
chronic disease to be managed, the current regulations require 
physicians to have to jump through enough hoops that they have to 
really, really want to prescribe bup. And most don't. "Doctors are 
afraid to treat addicts," says Dr. Stancliff of the Harm Reduction 
Coalition. "We don't learn anything about it in medical school. It's 
hard to convince them that it's incredible: prescribe someone 
buprenorphine today, and they come back in a week and say, 'that's a miracle.'"

When Obama signed the appropriations bill on Wednesday, it signaled 
that he's serious about his administration's new approach to 
addiction--and perhaps opened the door for other, more 
forward-thinking, programs. "If you take Obama's commitment, of no 
longer subordinating science to politics, and if you apply that 
seriously to drug policy," says the DPA's Nadelmann, "then there is 
no legitimate basis whatsoever for the federal government not to be 
supporting heroin maintenance and safe injection--research, at 
least--in the way that these other countries have. There's no 
legitimate basis whatsoever."
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