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A Prescription for Peace

Rapidly expanded maintenance prescribing could dramatically affect drug markets. But in order to work, such prescribing must be done right -- and in the right places.
 
 
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"Patriots Don't Use Heroin," was the headline on a recent column in the Cincinati Post, discussing the creation of a new anti-drug task force by the House. As Ohio Congressman Bob Portman, one of three co-chairs of the committee put it, "By Americans spending money on their drug habits, we are helping to support the Taliban government, which protects terrorism."

Or, as the Post's Washington Bureau chief Michael Collins wrote: "Real Americans don't do drugs." Leaving aside the questionable truth of that assertion -- 50 percent of us are physically dependent on caffeine, over half of adults have tried marijuana, 29 percent smoke cigarettes and half the population drinks alcohol regularly -- there certainly is something to the idea that black market drugs fuel large criminal organizations, including some that sponsor terrorism.

But calling on the patriotic fervor of deeply-troubled heroin addicts -- who are hard-pressed to stop to avoid losing their relationships with loved ones or even to avoid prison -- is unlikely to get many to quit. And worse, demonizing addicts creates an atmosphere which tends to preclude offering them the best treatment -- one of the few real and politically viable ways to shrink drug demand and the profits of criminals who benefit from it.

The State Department estimates that 72 percent of the world's heroin supply originates in Afghanistan. Unlike with cocaine, however, the West has a great weapon for fighting opiate addiction. Maintenance prescribing -- whether of heroin itself or of substitutes like methadone -- can be dramatically effective at reducing crime and returning addicts to productive lives.

For example, data from DATOS, the most recent major national treatment outcome study funded by the National Institute on Drug Abuse, shows a 64 percent drop in weekly or more frequent heroin use and a 48 percent drop in cocaine use after one year of methadone treatment. Illegal activity fell 52 percent. Compared to other types of treatment, methadone has been shown to be most effective for heroin addicts. And given in a steady dose, opiates like methadone do not impair addicts mentally, emotionally or physically: the worst side effect is constipation.

Between 1994 and 1996, the Swiss government conducted a study of another form of maintenance: providing heroin itself to addicts. Following over 1,000 participants, who were amongst the most impaired heroin addicts in the country, researchers found that after 18 months of treatment, only 5 percent of patients were using cocaine in addition to heroin and 9 percent were using benzodiazepines. Rates of permanent employment doubled-- and one third of those who started on welfare did not require benefits after 18 months. The number of criminal offenses committed by those in treatment dropped 60 percent during the first six months alone.

With those kinds of numbers, rapidly expanded maintenance prescribing could dramatically affect drug markets. But in order to work, such prescribing must be done right -- and in the right places.

Current U.S. and European regimes tend to stress avoiding diversion of drugs from patients into a "grey" market -- often at the cost of making barriers to treatment high and treatment itself a limit on freedom. (You can't travel, for example, if you have to appear at a clinic every day at a certain time to get your drugs.) As the Institute of Medicine put it in a 1995 review of the methadone regulations, "Current policy ... puts too much emphasis on protecting society from methadone, and not enough on protecting society from the epidemics of addiction, violence and infectious diseases that methadone can help reduce."

These priorities need to be reversed. Methadone should be made available with as few restrictions as possible to anyone who can show that he or she is physically dependent on opiates. Though federal regulations were recently loosened to some extent, the drug is still the most regulated substance in the American pharmacopeia and only about 10-20 percent of heroin addicts have access to it.

Diversion might even be seen as a secondary goal of such treatment. With methadone, diversion has little chance of spreading addiction to new users -- buyers of "street" methadone are almost always addicts who aren't in treatment, but want a break from heroin without bureaucratic hassles. Even with the most liberal prescribing practices, there will always be some who resist professional help. But if this group buys diverted methadone, that's money not spent on black market heroin.

If we were to try heroin prescribing, controls might need to be tighter -- but even if there is some diversion, this, too, is competition for the black market and at least diverted legal drugs start pure and in known quantities.

Expanded treatment could involve things like the use of "methadone buses" to keep NIMBY problems at bay, as has been done in Amsterdam. Regular doctors (not just the current specialized clinics) could be urged to prescribe methadone which would be obtained like any other prescription at a pharmacy -- something which is legal in the U.S. for the first time in decades under the new regulations.

Sadly for the rhetoric of anti-drug Republicans, only 5 percent of Afghanistan's heroin makes its way to America, according to the State Department. This means that our junkies couldn't do much for the war effort simply by kicking even if they wanted to -- but it doesn't mean that we shouldn't try to improve treatment by improving access to care and cutting crime, prison costs, AIDS and other blood borne infections, etc.

Europe, however, could make a real difference. About half of Afghanistani heroin goes to Europe according to the U.N. and experts estimate that close to 100 percent of heroin used in the U.K. comes from that country. Since the U.K. and many other European countries are already looking to reform ineffective and burdensome drug laws, this change may be politically possible there as well. The U.K., for example, already permits heroin prescribing and pharmacy pick-up of methadone.

As Peter McDermott, one of the directors of the UK Harm Reduction Alliance put it after introducing this idea to treatment providers in England on the group's Internet list, "Perhaps we should start to regard over-prescribing and the encouragement of the gray market as a blow for world peace?"

Maia Szalavitz is co-Author, with Dr. Joseph Volpicelli of University of Pennsylvania, "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems" (Wiley 2000).