Pubdate: Sat, 23 Apr 2016
Source: New York Times (NY)
Copyright: 2016 The New York Times Company
Author: Dan Levin


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, Mr. Napio, 55, 
gets his three daily doses from a nurse at the 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, 
Mr. Napio is spending time making gold and silver jewelry, hoping to 
soon turn his hobby into a profession.

"My whole life is straightening out," Mr. 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."

Mr. 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 yearslong 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.

The authorities in Vancouver, a bustling metropolis on the coast of 
British Columbia, 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," Sgt. Randy Fincham of the 
Vancouver Police Department said. "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 from 2009 to 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 first trial, known as the North American Opiate Medication 
Initiative, followed users from 2005 to 2008, and found that 
prescribing diacetylmorphine could save an average of $40,000 in 
lifetime societal costs per person compared with methadone treatment. 
The second trial, whose results were published this month in The 
Journal of the American Medical Association Psychiatry, found that 
injectable hydromorphone, a licensed pain medication, can be as 
successful as diacetylmorphine in treating a chronic opioid addiction.

But advocates say that some addicts cannot tolerate the side effects 
of hydromorphone, and worry that anything but heroin itself would 
send them back to the streets.

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."

Larry Love, 65, a gray-haired, jovial former oil rig worker, said he 
started using heroin at 13. Decades of addiction destroyed his 
marriage and relationships with his children. A $350,000 inheritance 
he received in the 1990s vanished in less than four years.

Diacetylmorphine, he said, has opened up a path back to normalcy. He 
compared it to the insulin injected daily by diabetics: just a drug 
he needs to stay alive.

"It's 100 percent about stability," he said. "Now I have money in my 
savings account and can get a haircut whenever I want. I've even 
started investing."

Advocates have long wanted to extend heroin maintenance beyond the 
small group of patients at Crosstown, but they face formidable 
bureaucratic hurdles and a continuing court fight.

In 2013, Canada's health minister, a member of the Conservative 
Party, sought to put in place regulations that would ban the 
prescription of heroin and other illegal drugs outside of a clinical 
trial, reflecting the party's broad opposition to harm-reduction policies.

Five Crosstown patients and the Providence Health Care Society, which 
runs the clinic, filed a case with the Supreme Court of British 
Columbia to block the move, arguing that the federal regulations 
violated a constitutional right to lifesaving treatment. A Supreme 
Court justice granted an injunction in 2014 that allowed current 
patients to continue receiving prescription heroin until the 
constitutional challenge could be heard. A court date is set for October.

At Crosstown, patients continue to try to repair their fractured lives.

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