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Spread of HIV & Harm Reduction

Douglas Coleman MD, CCFP, CASAM
Certified Consultant in Addiction Medicine
(Published in the BC Medical Journal Oct 99)

The views expressed are those of the author and are not necessarily those of the Royal Canadian Mounted Police or the Government of Canada.

Addiction to alcohol and other drugs is a disorder of the brain. Those responsible for dictating and implementing addiction treatment services in this province seem to have forgotten that. In so doing, they have allowed drug and alcohol policy discussions to be dominated by outspoken, but poorly qualified individuals and groups who have a clear cut agenda, which is uniquely their own. In particular, lobby groups push for ever more liberal access to drugs including methadone and "legal" heroin, the decriminalization of marijuana, an expansion of the needle exchange program (NEP) and the recognition of drug abuse as a lifestyle choice. Addicts and drug dealers are no longer patients requiring treatment or criminals requiring legal sanction: they have now become "clients" requiring services. All of this is offered under the rubric of "harm reduction" which proclaims the whole problem to be nothing more than a government policy mistake. It implies that changing the laws will eradicate the hazards associated with addiction, mental illness and HIV disease. This is absurd.

Addiction is a Disorder of the Central Nervous System

It is important to recognize the fact that all mood-altering substances profoundly disrupt the function of the central nervous system. The most evident manifestation of this disruption is euphoria, which is, in effect, the reason people use drugs(1). In addition to the change in mood, however, comes a profound impairment in judgement and impulse control, mood instability and impaired stress tolerance. Typically, addiction or chemical dependence manifests its earliest signs and symptoms in disturbed relationships. Families fall apart and partnerships disintegrate. Ultimately, the ability to work is compromised and, at the end of the process, jobs are lost and the addict is faced with a life of destitution. Although somewhat reductionist in its assertion, it is worth noting that drug addiction causes poverty, crime, and neuropsychiatric degeneration far more commonly than the reverse(2-4). In destroying close relationships and the ability to muster one's inner resources, individuals with addictions lose access to the supports that would normally see them through times of crisis or help them deal with chronic and debilitating illness. When large groups of such individuals are drawn to one area because of drugs and services that enable their addictions, and when the situation is further complicated by an epidemic of infectious disease and untreated mental health problems, the result is what has become so readily apparent in the Downtown East Side of Vancouver. There are effective treatments for chemical dependence. Those who developed the treatment program that has become the mainstay of most residential treatment facilities (the Minnesota model of treatment) have long recognized the fact that recovery from chemical dependence takes time. Addicts who successfully recover from their disease generally require months of supervised care. Inpatient programs may provide some of this treatment, but inevitably, the sine qua non of successful recovery depends upon the addict's willingness to surrender control of his or her treatment to some outside agency. This only makes sense given the profoundly disturbing effects addictive drugs have upon one's ability to think and feel. And abstinence is only the first step in a long recovery process. Without it, healing cannot occur.

Harm Reduction: Pragmatism or Resignation?

Unfortunately, the notion of abstinence-based recovery has fallen out of favor with those who currently fund treatment programs. Dominating the agenda is now the notion of "harm reduction," which generally implies that government policies should concentrate on lowering the harm to the individual, or the rest of society, associated with drug use, especially the risk of AIDS, rather than on reducing use itself or getting an addict off drugs. It is important to keep in mind that the term "harm reduction" means different things to different people. To some it implies widespread decriminalization of all drugs, easy access to heroin, and an abolition of all efforts to curb addiction by supply side reduction (criminal prosecution of drug dealers). To others, it means offering tightly controlled methadone maintenance and needle exchange programs to addicts, with every intention of moving them, ultimately, into abstinence-based treatment. There is no single definition of "harm reduction" and those arguing for its pre-eminent role in addiction treatment must be carefully scrutinized for an agenda that is in opposition to the notion of abstinence as the preferred treatment outcome.At present, one of the more alarming suggestions that is proposed by those pushing "harm reduction" is the notion of heroin injection sites in the Downtown East Side. If this becomes a reality and low threshold methadone maintenance (no need to comply with the traditional treatment protocols) becomes acceptable, drug addicts in Vancouver's downtown core will have virtually free access to all the drugs they can get their hands on. Accompanying these suggestions of ever-freer access to powerful mood altering chemicals is a virtual lack of any encouragement for the addict to actually stop using drugs. The message conveyed by these policies is one of fatalism and resignation. It deems the addict recidivist and discardable. Even though drug addicts may support such free access to drugs it is important to remember that when an addiction is active and "fed" it will always ensure its own survival. As mentioned previously, any drug that profoundly alters an individual's mood will have equally powerful and debilitating effects on that individual's ability to make appropriate decisions about what he or she needs. Simply insisting that drug use is a lifestyle choice will not make it so. Those with late-stage addiction, particularly when it is made worse by concurrent mental illness or physical disability, have virtually no choices. Their behaviors and actions are determined and driven by the demands of their addiction. It is society's responsibility to ensure that those so profoundly damaged are appropriately cared for. This does not mean acquiescing to every demand for yet freer access to heroin and methadone. It may, in fact, mean quite the opposite.

Partial Successes, Partial Failures?

We can learn by observing what is happening in other countries.Switzerland is often touted as an example of "harm reduction" in action. Its heroin distribution projects are seen as a success(5) despite a clear indication that this is not so(6;7). It is worth noting that Swiss adolescents use more drugs per capita than any other country in Western Europe(8). It is significant that in the Swiss Canton of Vaud those arrested for erratic driving or for their involvement in motor vehicle accidents almost always have drugs "on board" at the time of their arrest(9). These drugs include cannabinoids (57%), opiates (36%), alcohol (36%) benzodiazepines (15%), cocaine (11%), methadone (10%), and amphetamines (4%). The majority (58%) test positive for more than one drug. Switzerland's liberal, drug policies should be seen as causes of, not responses to, these circumstances.Even if one was to concede (under duress) that Switzerland's laissez faire drug control policies were somewhat successful in reducing the collateral damage due to drug abuse, the full story remains untold. The public here in British Columbia, our local and provincial politicians, and the relevant law enforcement stakeholders are never given the full story on how Switzerland is attempting to cope with its drug and HIV problem.Geographically, Switzerland is about the size of Vancouver Island. It is divided into 26 Cantons. Although we hear about the liberal drug policies so prevalent in Switzerland, we seldom hear about some of the more restrictive measures that may be responsible for some of their "harm reduction" policy's partial successes.There are other notable differences. In 1993, Switzerland's 25,000 drug addicts and alcoholics had access to 5000 detox and 1300 residential treatment beds. Today, by comparison, those seeking addiction treatment in B.C.'s Lower Mainland have access to 81 detox beds and a similarly inadequate number of inpatient treatment slots. As well, the Swiss government has mandated "decentralized" drug treatment. Drug addicts seeking treatment or arrested for drug related crime in one Canton can be held against their will and, thereafter, compelled to return to their home Canton for treatment(10). This prevents any given locale from being overwhelmed by treatment demands, and prevents the complete social disintegration of areas that would otherwise be forced to serve as treatment areas for uncontrollable numbers of intoxicated and disinhibited addicts. The most obvious implication for such a policy, if similarly implemented in British Columbia, would be an immediate drop in the number of addicts requiring services in the Downtown East Side. Addicts living in the downtown core whose homes were originally elsewhere would be compelled to return to their community of origin. This would significantly lower the burden placed upon the residents and resources of the Downtown East Side. Without this critical mass of chemically dependent individuals attracted to and serviced by the centralized services of downtown Vancouver, the problem would become much more manageable. This sort of "mandated" recovery is a critical piece of the puzzle that no one, up until now, wants to discuss. The role for law enforcement in establishing and maintaining this state of affairs is clear and compelling. There are, however, implications that would follow from such a decentralization policy. Communities with clearly defined catchment areas must be able to offer limited methadone maintenance, detoxification, inpatient treatment and monitored support recovery. Those communities must be identified, the services must be comprehensive, and the appropriate financing must be made available.There are also lessons to be learned from countries that have avoided the "harm reduction" approach to addiction and HIV treatment altogether.Sweden is a country comparable in size to British Columbia. It has between 15 and 20 thousand intravenous drug addicts, many of whom are clustered in the Stockholm area. This large number is due, in part, to Sweden's previously liberal drug policies. Since the early 1980s, however, Sweden has changed its drug policies and, as a result, most of these intravenous drug users are older. There has not been the rapid increase of new i.v. drug users "coming on stream" like there has been in British Columbia. Sweden's NEP is very small and tightly controlled as is its methadone maintenance program. The availability of drugs is kept low by vigorous police action. Individuals are arrested and charged for even small amounts of drugs (including marijuana) and the police force works hand in hand with the drug treatment agencies. Individuals are commonly given a choice of jail or treatment, and most, obviously, choose treatment(11). There are, as well, communicable disease laws, which allow HIV positive individuals who engage in risky behaviors to be mandated into treatment. In the twelve years since the passage of Sweden's Communicable Diseases Act (1986) there have only been 63 "committals" to this sort of treatment. Most of the individuals so committed have been HIV positive i.v. drug users who continued using drugs and engaging in behaviors that were considered high risk for spreading HIV (12). The most significant value of this law is its deterrent effect(13). The results have been astonishing. In 1994, for instance, among Stockholm County's intravenous drug users, there were only 18 HIV seroconversions. Sweden's restrictive drug policy, its comprehensive drug treatment programs, its extremely limited methadone and needle exchange program and the Communicable Diseases Act of 1986 have clearly, from an HIV and addiction perspective, left Sweden in an enviable position.Other European countries with liberal drug control policies, and which are commonly viewed as "harm reductionist" in their approach to addiction treatment have long recognized the need for a robust and high profile role for their law enforcement agencies in an effort to make those policies work. The Netherlands, often seen as the home of legal marijuana and hashish, has no trouble forcing addicts who have committed crimes into treatment by virtue of a court order(14). The value of coercive treatment has been universally recognized(15). Legal sanctions are but a single form of this coercion, and are most appropriately applied when criminal behavior is so commonly part of the addictive disorder. This is done in order to break the link between illness and crime, not to punish.

Problems Close to Home

There is some disturbing news coming from our own backyard.The report recently released by the Vancouver/Richmond Health Board's Public Health Officers providing suggestions on how to deal with the HIV epidemic in i.v. drug users completely excluded any mention of a role for law enforcement agencies(16). Attempting to control an HIV epidemic driven by i.v. drug addiction without involving the police as a major stakeholder is doomed to failure. This reports recommends "client driven" treatment policies. Asking addicts what they want and then providing it to them, once again, fails to take into account the profound compromise of mental function inherent in the addictive disorders. These policies are doomed to fail. They have not worked in the past and there is every reason to believe they will continue to fail. The stakes, however, are getting higher.Ignoring the lessons of countries that are doing much better than we are in treating their addictive population and thus controlling their HIV epidemic is foolhardy. Unless we can learn from the lessons of others we are doomed to fail. Recent data from the VIDUS study has pointed out a clear association between Vancouver's needle exchange program and the spread of HIV. Those attending the local NEP are at greater risk of converting to HIV positive status than those who do not attend(17). Seventy eight percent of those attending Vancouver's NEP get all their syringes from this source. Despite ready access to free needles (2.4 million distributed last year), 40% of those obtaining their needles from the NEP continue to share them. This is an alarming association and we must vigorously question the value of continuing to provide such easy access to injection equipment when it is so freely shared.Lest this association between attending our local NEP and the risk of spreading HIV be considered a spurious anomaly it is worth looking at NEP's in other areas of Canada. A recent investigation of Montreal's NEP clearly demonstrated that NEP attendance predicted an increased risk for HIV seroconversion. No matter how the researchers examined the data, this association remained(18). Other studies in Europe have raised similar concerns about a NEP's role in reducing the spread of HIV infection(19), and in these studies it is apparent that attendance at NEP clearly did not reduce the tendency for those attending to share their needles. We ignore these observations at our own peril.

Legal vs. Illegal Drugs

Heroin injection site advocates and those proposing a widely expanded low threshold methadone maintenance program ignore the driving force behind addiction. To assume that "street drug" addiction is damaging only because the drugs are illegal flies in the face of virtually everything that is known about addictive disorders. It ignores the fact that in Canada, drugs that are legal and socially accepted (nicotine and alcohol) cause most of the problems related to substance abuse or dependence. This assumption, too, fails to account for the fact that a significant number with chemical dependence problems have difficulties because of prescription drug misuse. These medications often have effects only on the brain, do no harm to other organ systems, and have no legal consequences because of their use. Nevertheless, they cause enormous suffering and social disruption(20-24). It also suggests that those with opiate dependencies that have free and ready access to narcotics (health care professionals and pharmacists), and who engage in no obviously criminal behaviors should have no real problems because of their addictions. This is obviously not the case(25-28). The "high" so desired by addicts is the thing that compromises rational thought. It is the desire for euphoria that drives this problem. If addicts cannot take enough methadone to produce this euphoria they will use other drugs, notably cocaine, alcohol, marijuana and Valium. What is even more worrisome is the urge some authorities have to "flood" Vancouver's Downtown Eastside with methadone, failing to recognize that the drug of choice in this area is cocaine. The combination of cocaine and methadone is lethal, producing a "high" which is more powerful than that caused by either drug used alone(29). Given these circumstances, addicts will continue to use drugs until they either end up dead, institutionalized or, if they are lucky, in abstinence-based recovery. To expect them to give consideration to "safe sex" practices and to make rational decisions about sharing their injection equipment while so intoxicated and mentally compromised is, at best, unrealistic.Methadone may stabilize an addict until he or she musters his or her resources sufficiently to move out of the downtown core and into more appropriate treatment circumstances. No one can argue with safer housing and adequate health care. To concentrate these services in the Downtown East Side, however, does nothing more than attract yet more addicts to an area rife with HIV and inexpensive heroin and cocaine.Finally, it must be pointed out that those who beat the "harm reduction" drum most loudly appear to have an inordinate fondness for declaring to anyone who will listen, that "marijuana is not a dangerous drug." Without going into detail it bears mentioning that some of those who most vigorously advocate for decriminalization of marijuana do so in order to legitimize their own drug using behaviors. They fatuously declare that there is no evidence to support claims that marijuana is hazardous or addictive. This is patently untrue and anyone with a desire to find well conducted studies (pharmacological, epidemiological, etc) proving otherwise can do so easily with a little effort(30-34). Others appear to advocate for marijuana decriminalization for more altruistic reasons but do so without a full appreciation of how marijuana use can cause problems for those at risk for developing addiction.

What's Next?

There are solutions to this problem of i.v. drug abuse and rampant HIV disease.Legislation compelling treatment for HIV positive drug addicts is a good start. Involving the police as a major player in any public health debate and subsequent policy implementation is critical. Immediate funding for detoxification and treatment facilities is the foundation upon which to build successful recovery programs. The public must be made aware of the fact that there is more to offer addicts than heroin and methadone. Those prescribing methadone must receive more comprehensive addiction medicine training than is currently the case. The "enabling" needle exchange programs should be sharply curtailed and made more accountable. We must not be confused about marijuana's dangers. Every effort should be made to move addicts out of the Downtown East Side and back into their home communities. Doing so without adequate facilities in those outlying communities will, however, result in failure.Drug addicts clearly have an invaluable role to play in determining and refining effective addiction and HIV treatments. We must pay special attention, though, not to those who are still in the grip of their disease, but to those who are securely abstinent and effectively on the road to recovery, and who have become useful and productive members of society. Their insights are profound and freely given, and many are willing to participate in this ongoing dialogue. We must invite them to the table, however, and listen carefully to what they have to say.

The addiction and HIV agenda must not be dominated by those who see drug use as a lifestyle choice. A restrictive drug policy integrated with mandated and comprehensive treatment has been proven effective. All we need now is a government courageous enough to act.

Reference List

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