Pubdate: Fri, 22 Apr 2016
Source: Boston Globe (MA)
Copyright: 2016 Globe Newspaper Company
Contact: http://services.bostonglobe.com/news/opeds/letter.aspx?id=6340
Website: http://bostonglobe.com/
Details: http://www.mapinc.org/media/52
Author: Dan Levin, New York Times

VANCOUVER FIGHTS OPIOID CRISIS WITH PRESCRIPTIONS FOR ADDICTS

VANCOUVER, British Columbia - Dave Napio started doing heroin over 
four decades ago, at 11 years old. Like many addicts these days, he 
heads to Vancouver's gritty Downtown Eastside neighborhood when he needs a fix.

But instead of seeking out a dealer in a dark alley, Napio, 55, gets 
his three daily doses from a nurse at Crosstown Clinic, the only 
medical facility in North America permitted to prescribe the narcotic 
at the center of an epidemic raging across the continent.

And instead of robbing banks and jewelry stores to support his habit, 
Napio is spending time making gold and silver jewelry, hoping to soon 
turn his hobby into a profession.

"My whole life is straightening out," Napio, who spent 22 of his 55 
years in prison, said during a recent interview in the clinic's 
mirror-lined injection room. "I'm becoming the guy next door."

Napio is one of 110 chronic addicts with prescriptions for 
diacetylmorphine hydrochloride, the active ingredient in heroin, 
which he injects three times a day at Crosstown as part of a 
treatment known as heroin maintenance. The program has been so 
successful at keeping addicts out of jail and away from emergency 
rooms that its supporters are seeking to expand it across Canada. But 
they have been hindered by a tangle of red tape and a years-long 
court battle reflecting a conflict between medicine and politics on 
how to address drug addiction.

The clinic's prescription program began as a clinical trial more than 
a decade ago. But it has garnered more interest recently as a plague 
of illicit heroin use and fatal overdoses of legal painkillers has 
swept across the United States, fueling frustration over ideological 
and legal obstacles to forms of treatment that studies show halt the 
spread of disease through needles and prevent deaths.

Canada and some European countries have long permitted needle 
exchanges and monitored injection sites. Prescription programs like 
Crosstown's, for addicts whom replacement drugs like methadone do not 
seem to help, have been available for years in Britain, Denmark, 
Germany, the Netherlands, and Switzerland. All these countries have 
reported significant decreases in drug abuse, crime, and disease.

But such programs have been stymied in the United States, where 
overdoses have lately led to 125 deaths per day, by concerns that 
they would encourage illicit drug use. In February, the mayor of 
Ithaca, N.Y., was criticized by some Republican officials, 
rehabilitation professionals, and police officers after he proposed 
to establish the country's first supervised injection facility.

Authorities in Vancouver say they turned to such programs after more 
traditional criminal justice approaches failed to stop rampant 
illegal drug use and sales on the Downtown Eastside, a poor 
neighborhood notorious for addiction and crime.

"We tried to arrest our way out of it and that didn't work," Sergeant 
Randy Fincham of the Vancouver Police Department explained. "Clogging 
up our courts and jails was not the solution."

The city started, in 2003, with North America's first legal injection 
facility, InSite, which currently serves around 800 people each day. 
The addicts bring their own drugs, and InSite provides clean needles 
and medical supervision. The organization has recorded no fatal 
overdoses on its premises, and said overdoses near the facility have 
decreased by 35 percent since 2003, compared with a 9 percent 
decrease throughout Vancouver.

More broadly, a study by the British Columbia Center for Excellence 
in HIV/AIDS found that people who use safe injection sites are 30 
percent more likely to enter detox programs and 70 percent less 
likely to share needles.

Legal injection sites do not, however, address the thefts, 
prostitution, and other criminal behavior that participants often 
rely on to finance their addiction. And heroin sold on the street is 
often combined with - or surreptitiously replaced by - fentanyl, an 
opioid up to 50 times as potent that was a cause or contributing 
factor in 655 deaths across Canada between 2009 and 2014, according 
to the Canadian Center on Substance Abuse.

Participants in the Crosstown prescription program do not have to 
worry about the purity of their drugs.

To get a diacetylmorphine prescription from the clinic, patients must 
have participated in two earlier clinical trials on heroin 
maintenance, whose eligibility requirements included more than five 
years of injecting opioids and at least two failed attempts at 
replacement therapy, one of which with a treatment such as methadone.

The diacetylmorphine prescription program is one of several 
addiction-treatment services at Crosstown, a squat gray clinic that 
opened in 2005. The publicly funded program costs about 27,000 
Canadian dollars, or $21,000, per addict per year. (The Journal of 
the Canadian Medical Association published a study in 2012 that 
estimated that an untreated, severe opioid user costs taxpayers at 
least $35,000 a year in medical care, jail and other expenses.)

Patients can visit the clinic up to three times a day, from 8:30 a.m. 
to 4 p.m. They enter through a security door and fill a white-walled 
waiting area before taking seats in the injection room, where nurses 
give them a needle and an average dose of 200 milligrams of 
diacetylmorphine. The process takes a few minutes, but the effect is profound.

"We've seen people make dramatic changes in their lives," said Dr. 
Scott MacDonald, the clinic's lead physician. "They don't have to 
hustle or do sex work anymore, and some are now able to go to school 
or work. It's very rewarding."

Liane Gladue, 48, was a seventh-grade teacher and a married mother 
before she started shooting heroin two decades ago. She said she 
could not quit and spent her waking hours shoplifting and committing 
other crimes. But since joining the clinical trials and Crosstown's 
program, she said, she has reconnected with her grown children.

"When I wake up and think about what I'd have to do for heroin, I 
feel so lucky to be in this program," she said. "Now I can do some healing."
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MAP posted-by: Jay Bergstrom