Chinks are appearing in the armor of the present repressive and anti-therapeutic approach to drug issues in our society, endorsed and nurtured by the Federal Administration in Washington over the past 11 years.
Since the Harrison Act of 1914, those citizens addicted to illicit drugs have received short shrift in terms of decent treatment. Criminalized by the necessity to acquire prohibited chemicals to satisfy craving and to prevent withdrawal symptoms, they generally wind up in the hands of the law and are imprisoned. The farfetched hope that they will "learn their lesson" and stay away from drugs on release from jail is usually not realized as relapse is commonplace, especially with opiate dependence.1 The adverse impact on the public health of ongoing drug use is manifested by the rising incidence of HIV infection among intravenous injectors.2 In addition, drug resistant tuberculosis is resurgent in the disenfranchised, poverty stricken minority segment of our society where drug use is rampant and lack of basic hygiene is commonplace.3
Hepatitis B infection has long been associated with the use of contaminated injection paraphernalia and sexual activity.4
Communicable disease as a cofactor of drug use is forcing public authority to change attitudes and viewpoints in respect to those that are consumers of chemicals that are illicit and are used parenterally. No more vivid or more accurate description of urban drug problems and their potential for widespread harm to others can be found than in the six-part series of articles about drugs and drug users published in the Hartford Courant in January 1992.5 Whereas in the past addicts could be safely ignored, the present risk of injury to others is cause for concern regarding their health and welfare. This change in approaching problems of compulsive drug use unfortunately is not gratuitous, but rather intrinsically selfish and self-serving from society's standpoint. Yet it is a step in the right direction.
An example of this change in attitude is the recent acceptance of needle exchange as a prophylactic measure to stem the rise in the incidence of HIV infection among drug injectors. In Connecticut over-the-counter availability of injection paraphernalia was prohibited until the repeal of this legislation in the current session of the General Assembly in Hartford. The impassionate, critical assessment of the pilot needle exchange program in New Haven established by the Assembly in the previous year was responsible for the passage of this landmark legislation.6 In addition, legal needle exchange has been expanded by statute. These bills await Governor Weicker's signature. The legislature dealt pragmatically with the adverse public health aspects of drug injection, abandoning moralizing about the unproved risk of inducing additional drug use through needle and syringe availability. The New Haven needle exchange program is presently serving as a model for the establishment of similar legal programs in California and Maryland. New York City is currently instituting exchange despite opposition from the tederal administration represented by Mr. Martinez in Washington.
The fact that the political establishment is recognizing compulsive drug use as an issue relating to the health of society will eventually have far-reaching consequences, hopefully beneficial, for addicts. The intractability of dependence on drugs, the frustrating tendency to relapse despite treatment, is being viewed by many not as a moral, ethical or criminal issue but as the result of a neurological illness brought about by the biological changes wrought in the brain by these chemicals.
The disease concept of addiction is understood and accepted by increasing numbers of those in civil authority. The understanding and cooperation of the political and police establishments are critical to the success of legal needle exchange. No better example of the beneficial results of this cooperative and therapeutic attitude exists than in New Haven, Connecticut where Police Chief Nicholas Pastore has stated his support publicly for the disease concept of addiction and the need for police to facilitate treatment.7 What a far cry this humane approach to policing drug users is from that of Chief Daryl Gates of the Los Angeles Police Department. He stated in testimony before the Senate Judiciary Committee in 1990 that" casual users ought to be shot if there are any casual users."8 No wonder a state of war exists between the minority communities and the Los Angeles police.
The grudging acceptance and support for methadone maintenance in the treatment of heroin addiction is a welcome sign that society is reevaluating the goal of total abstinence as unattainable in many cases and that substitution treatment can be effective in normalizing the addict's life. The oral route of methadone administration obviates injecting and, if the addict is HIV negative, reduces the risk of HIV infection through needle sharing. If the methadone client is HIV positive, oral dosing is a preventative measure for those who otherwise might share injection paraphernalia with that individual.
Because methadone clinics and needle exchanges are entities that interface in a therapeutic manner with the addict, their role in general health care needs to be extensively and rapidly expanded. They are the logical sites for medical care for those infected with HIV and other STDs, tuberculosis and hepatitis B. This means that the highly regulated bureaucratic system of methadone dispensing must give way to a medically oriented system of care emphasizing client needs in respect to physical and mental health. Rules relating to strict abstinence from drugs other than opiates must be revamped to allow those addicted to multiple agents to continue to participate as clients especially if they are ill with other diseases such as AIDS or TB. Detoxification and dismissal from the program to resume the use of street drugs and behavior placing others at risk is illogical under present conditions, at least for the time being. Positive promotion of methadone to enlist larger numbers of drug injectors and to counter the anti-methadone messages from drug merchants is necessary now.
Presently methadone clinics and needle exchange, having drug counselors available, counsel and refer clients for detoxification and abstinence treatment on request. The frequency of dual diagnosis, addiction and depressive illness is high in this population. Appropriate chemotherapy and follow-up for depressive illness can be carried out by the physician participating in these programs.
To extrapolate a future role of methadone and needle exchange programs still further, it is feasible that they become centers for the controlled distribution of those psychoactive chemicals now held to be illicit and available only through the black market, chiefly heroin and cocaine. These agents could be dispensed through pharmacies by prescription to addicts so diagnosed medically. Casual users would not be included in such a program of distribution.
The prototype for such a program exists in Liverpool, England today. Its success is marked by the low rate of HIV infection among Liverpool's drug injecting population - single digits as compared to 50-60% in New York and Connecticut. The rate of acquisitive crime suh as muggings and burglaries has declined by 40% in a city suffering from 25% unemployment and difficult economic times. The rate of new users is also low, probably because the legal dispensing of reasonably priced drugs lessens the demand for a black market and reduces pushing of illicit drugs by black marketers. Because the drugs prescribed are clean and unadulterated and of constant potency, the complications of overdose and the harmful effects of impurities are avoided.
In summary, a new day is dawning as addicts are being seen as people who are ill and in need of definitive care in order to lessen the risk they impose on society at large. Facilities for care giving are in place but need promotion and wider expansion. The future should include the controlled distribution of psychoactive chemicals in a hygienic fashion to allay craving and to prevent withdrawal symptoms for addicts.
1 Brecher EM: Licit and Illicit Drugs. Boston, Little Brown 1972
2 Hahn RA et al: Prevalence of HIV infection among Intravenous Drug Users in the United States. JAMA 1989;261:2677-84
3 Novick,A: Resurgent Tuberculosis in HIV infected Persons. AAPHR Reporter Spring 1992:4-6
4 Mezzelani P et al: High Compliance with a Hepetitis B virus vaccination program among IVDUs. J. Infect. Dis. 1991; 163(4) 293
5 0tto M & Clift B: Streets of Despair - Addiction, Prostitution and the Specter of Aids. The Hartford Courant Jan. 19-23 1992
8 0'Keefe E, Kaplan E, Khoshnood K: Preliminary Report City of New Haven Needle Exchange Program, 1992 July 31, 1992
7 Trebach A & Zeese K: The Great Issues of Drug Policy, Washington, DC: The Drug Policy Foundation 1990: Preface iii 8ibid