Monday, August 20, 2018
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A move by the US Congress has expanded the availability of buprenorphine treatment for opiate addiction. The Baltimore Examiner reported on Dec. 19, 2006 ("Congress Improves Heroin Treatment Options") that "Organizations such as Sheppard Pratt Health System can now treat more than three times as many heroin addicts with the highly effective drug buprenorphine, thanks to a move by Congress to amend the Controlled Substances Act. The changes, approved Dec. 8, raise from 30 to 100 the number of patients a clinic or hospital can treat with the drug."
According to the Examiner, "That is a boon to drug abuse counselors and to addicts in the Baltimore region, said addictions educator Michael Gimbel, of Sheppard Pratt. 'This is a very important piece of legislation. It will immediately allow us to treat more heroin and opiate addicts. Buprenorphine seems to be a very effective alternative to methadone in treating addicts.'"
The Examiner noted that "The drug is the only controlled medication doctors may prescribe in private practices with certification. However the law still has flaws, Sheppard Pratt spokeswoman Bonnie Katz said. The entire Sheppard Pratt system can only treat 100 patients with the drug, she said, which is a deterrent to spending the money to train and certify additional doctors."
The Senlis Council, an international drug policy think thank based in Europe, finally issued its controversial recommendations regarding Afghan opium in Sept. 2005. Reuters reported on Sept. 25, 2005 ( "Afghanistan Not Ready For Legal Opium - Minister") that "Afghanistan, the world's biggest producer of illicit opium and heroin, is not ready to adopt a controversial proposal to use its opium to help ease a global shortage of painkillers, its counter-narcotics minister says. The Senlis Council, a Paris-based non-governmental organisation, has suggested licensed Afghan opium production could be used to produce morphine and codeine and is to a launch a feasibility study on the proposal in Kabul on Monday."
Opposition to the idea also comes from the UN drug fighting agency, the United Nations Office on Drugs and Crime. According to Reuters, "The United Nations Office on Drugs and Crime (UNODC) has also rejected the Senlis Council proposal, saying it risked creating confusion among farmers and raising false expectations. Senlis has estimated the worldwide shortage of morphine and codeine at about 10,000 tonnes of opium equivalent a year, while Afghanistan produces roughly 4,000 tonnes of opium a year. However, the UNODC, while conceding there is a shortage of narcotics for medical purposes, says lawful production of opiates worldwide had considerably exceeded global consumption in the past years and could be increased should demand increase."
The shortage of opiate medicines even hits the nations which currently produce legal opium. The San Jose Mercury News reported on July 15, 2005 ( "Crime And Politics Of Opium Trade") that "India is the world's largest producer of legal opium, the raw material for codeine, morphine and other painkillers. But corruption and red tape have left thousands of Indians such as Nevatia to die in agony. And strict licensing hasn't stopped drug gangs from diverting opium meant for medicines to smuggling routes shared by heroin and morphine traffickers, gun-runners and Islamist militants, police say. 'Organized crime and politics join together in this to make life miserable,' said A. Shankar Rao, zonal director of the Narcotics Control Bureau, a national police unit."
According to the Mercury News, "Mala Srivastava, the federal official who oversees the licensing system, denied that it had serious flaws. 'Whatever little diversion there is is internal,' she said. 'We have never heard of Indian opium, or Indian heroin, traveling abroad.' But the U.S. State Department's annual report on narcotics-control strategy calls India 'a modest but growing producer of heroin for the international market.' In an effort to keep opium out of criminal hands, India's federal and state governments license every step of the process, from growing poppies to stocking and transporting the painkilling drugs they produce. But officials who issue the permits often don't answer the phone, are away from their desks or let applications languish for weeks, doctors and pharmacists complain. Sometimes hospitals run out of morphine while waiting for permit applications to work their way through the bureaucratic labyrinth. 'We have so many patients suffering,' said Dr. Dwarkadas K. Baheti, a pain-management specialist at Bombay Hospital, in India's largest city, Mumbai. 'After two or three months, suddenly we have no morphine left, and for the next month, none is available.'"
The Mercury News noted that "But licensing hasn't stopped traffickers, aided by corrupt officials, from getting opium and other drugs, Rao said. 'With the support of local police and politicians, they convert this opium into 'smack,'' slang for heroin, said Vinod Kumar Shahi, a lawyer in Lucknow, capital of northern India's Uttar Pradesh state. Shahi has learned a lot about the drug trade in 20 years of defending many of the region's top gangsters. By helping traffickers, police can earn 50 times their official monthly salary of about $230, Shahi said. So they pay large bribes to superiors to be posted at police stations in the opium belt of northern India, he said. Tons of tarlike opium gum are skimmed off India's legal supply each year and sent to ad hoc chemists. With a plastic tub, a cup and chemicals easily found on the black market, they make the low-grade heroin base known as 'brown sugar' on the street. There, illegal morphine is worth as much as 25 times what the government pays for it, Rao said. India is a transit country for almost-pure Afghan heroin, which is smuggled in from neighboring Pakistan, often in inflated tire tubes that are floated across rivers along the border. The high-grade heroin produced from Afghan opium accounts for about 87 percent of the world supply, according to the United Nations. Indian drugs also go south to Sri Lanka, where guerrillas with the Liberation Tigers of Tamil Eelam use money from heroin trafficking to fund their war for independence. Meanwhile, those who need the painkilling peace that opium-based drugs brings go without."
Download the Senlis Council's Feasibility Study on Opium Licensing in Afghanistan for the Production of Morphine and Other Essential Medicines from here, or from the Senlis Council's website.
The state of New Jersey issued its 2003 New Jersey Household Survey on Drug Use and Health on Sept. 19, 2005. According to the state Dept. of Human Services ( "New Jerseyans Smoke, Drink, Do Drugs Less But Use Heroin More"), "New Jersey residents in general tend to smoke, drink and use illicit drugs less than the national average; however the incidence of heroin abuse in New Jersey is higher than the rest of the country."
In fact, according to the Associated Press story on Sept. 20, 2005 in the Home News Tribune ( "Jersey's Rate Of Heroin Use Double The National Average"), "Heroin is used by 18- to 25-year-olds in New Jersey at more than twice the national average, and officials who released a report on drug abuse yesterday said the highly addictive drug is easy to get in the Garden State. While marijuana was reported to be the most-tried illegal drug in the state, the federally funded report showed that 5 percent of young adults had heroin habits, compared to 2.5 percent nationally. New Jersey's shipping ports, small geographic size and high population density make distributing heroin easier here than in other states, said Carolann Kane-Cavaiola, assistant commissioner for the state's Division on Addiction Services. 'We're the first ones that get it,' Kane-Cavaiola said. 'In New Jersey, the DEA ( U.S. Drug Enforcement Administration ), along with other law enforcement and emergency rooms know that we have the best and cheapest heroin in the country.' The results of the 2003 New Jersey Household Survey on Drug Use and Health have prompted officials to plan to open two more methadone clinics, in Ocean and Gloucester counties. The expansion is the first in more than a decade and will bring to 36 the number of centers around the state where heroin addicts can receive legal drugs to help wean them off heroin."
The AP noted that "Residents also lag behind the rest of the country in getting treatment, a serious concern for officials since drugs are a major factor in child abuse, poverty and homelessness, and can contribute to mental illness. Those treated for drug addiction, including alcohol and tobacco, are expected to increase from 61,000 in 2003 to 65,000 in 2006."
AP reported that "The report found that New Jerseyans are smoking more cigarettes but drinking less alcohol and using less illegal drugs than they were in the 1990s. But because the adults surveyed were interviewed over the phone, illegal drug use is likely to be seriously underreported, according to the survey. Estimates for residents having had alcohol ( 87 percent ) or smoked cigarettes ( 58 percent ), often more socially accepted behaviors, were expected to be more accurate."
The City of New York's Health Dept. began a potentially significant promotion of Buprenorphine treatment for the city's opiate addicts. New York Newsday reported on July 10, 2005 ( "New Option To Wean Off Heroin") that "In an unusual move, city Health Department officials are quietly encouraging physicians, hospitals, methadone clinics and prisons to prescribe the drug buprenorphine to heroin addicts, believing it will lure more addicts into treatment. Buprenorphine - a relatively new drug that goes by the nickname 'bupe' and comes in a pill form - offers a new set of treatment options for opiate abusers, said Dr. Lloyd Sederer, executive deputy commissioner of the city Department of Health and Mental Hygiene."
The Health Department's goals are ambitious. According to Newsday, "Despite the potential benefits of buprenorphine, the drug remains virtually unknown and unused by the city's heroin addicts. According to city health officials, only about 1,000 people use it, compared with an estimated 34,000 taking methadone. Sederer and other city health officials want to see a significant change in those numbers. The goal is to have more than 100,000 opiate addicts using buprenorphine for detox maintenance by 2010. 'We are not reaching enough people with the treatments that we have,' Sederer said. 'Not everybody should be on methadone.' Like methadone, buprenorphine is heavily regulated, and may be prescribed only by certified doctors, of which there currently are 345 statewide. In addition, those prescribing the drug are bound by a 30-patient limit, a federal restriction guarding against prescription abuse that Sederer and other health officials hope will be changed so that more patients can be treated. Some private doctors have been reluctant to prescribe the drug, fearing their offices would be inundated with addicts. The drug's pill form would be more attractive to white-collar users trying to avoid methadone clinics, experts said."
The size of New York City's addicted population and the current costs of treatment are staggering. Newsday noted that "The goal, drug treatment experts said, is for more doctors to be able to prescribe buprenorphine and for patients to be able to pick it up at the pharmacy. Potentially, thousands of people could benefit from the drug. The city spends $50 million annually on treatment of an estimated 200,000 heroin addicts and 200,000 others addicted to prescription painkillers like Vicodin, Percocet and OxyContin. The state Office of Alcoholism and Substance Abuse Services will spend $313.7 million in 2005-06 to treat those battling against alcohol and other drug-related addictions, spokeswoman Jennifer Farrell said. 'Buprenorphine expands the availability of treatment for those who are addicted to opiates and allows recovering addicts to more likely follow treatment to completion,' Farrell said. Opiate addicts on buprenorphine for maintenance have a better chance of working because it has fewer side effects than methadone, Sederer said. Also, having more opiate addicts in recovery would reduce crime and the spread of HIV and other diseases related to needle use, he said."
The first clinical trial of prescription heroin in North America began in Feb. 2005. As the Canadian health ministry, Health Canada, wrote in its news release of Feb. 9, 2005 ( "North America's First Trial Of Prescribed Heroin Begins Today"), "The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs. The NAOMI study will enrol 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring. Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months."
"According to Health Canada, "In 1973 the federal Commission of Inquiry into the Non-Medical Use of Drugs recommended that heroin-assisted therapy be tested in clinical trials. More recently, large studies in Switzerland and the Netherlands have indicated that heroin-assisted therapy is useful in helping some chronic users to stabilize their addictions, reduce criminal activity and lead more healthy and productive lives. The Canadian Institutes of Health Research (CIHR) is providing at total of $8.1 million and the study is approved by Health Canada. The principal investigator is Dr. Martin Schechter of the University of British Columbia Faculty of Medicine. Ethical review boards at each of NAOMI's three sponsoring institutions-the University of British Columbia, Toronto's Centre for Addictions and Mental Health and Université de Montréal-have approved the study. 'Results from the European studies suggest that medically prescribed heroin could greatly help our most troubled heroin addicts --those for whom we have no effective treatments,' said Dr. Schechter. 'But we won't know whether the same results hold true in the Canadian setting until we complete this carefully designed scientific study.' 'Heroin addiction afflicts an estimated 60 to 90,000 Canadians and the costs associated with it--in terms of human misery, public health, social problems and crime--are staggering,' said Dr. Alan Bernstein, President of CIHR. 'Canada, and many other countries, therefore, need studies such as NAOMI to investigate new approaches to reducing the harm caused by heroin addiction.'"
Though the plan has some critics, particularly the US Office of National Drug Control Policy (the 'Drug Czar'), many are lining up in support of the NAOMI project. The Globe & Mail reported on Jan. 31, 2005 ( "Is Free Heroin Just A Quick Fix?") that "In Vancouver, the plan has the support of top politicians and law enforcers, including the mayor and the police chief. Mayor Larry Campbell, who was once a coroner and drug cop, said the trials are needed because current treatments aren't working for hard-core addicts. 'The critical thing is to accept this as a medical condition,' Mr. Campbell said. 'The side effects of this medical condition is that it forces you to . . . do things that you would never do, be it work as a sex-trade worker, be a B and E [break-and-enter] artist or a purse snatcher. So if I can mitigate that by putting you on heroin, imagine the changes you could have.'"
A report by researchers in Glasgow, Scotland, has stirred a debate in the United Kingdom over the question of controlled heroin use. BBC News reported on Feb. 3, 2005 ( "Heated Debate Over Heroin Report") that "The Glasgow Caledonian University study of 126 users of the class A drug found many were holding down normal jobs and relationships and passing exams. The report said heroin could be taken in a controlled way for a period."
Critics panned the report as promoting heroin use. Calmer voices explained that this was not the case. According to BBC, "However, Lord Victor Adebowale, the chief executive of specialist alcohol and drug organisation Turning Point, said the report was not saying that heroin was safe. He explained: 'It says that if you have a job, if you have a house, an income, are well educated and have a health system to support you, it's possible to survive an addiction to a pretty serious substance. Most people don't have this and have mental health challenges as well as a heroin problem.'"
Indeed, even the study's author stressed that the report should not be taken as minimizing the danger of heroin. As the BBC noted, "The report's author, Dr David Shewan, agreed that heroin was not a safe drug. He said the concept of controlled drug use was a 'largely unexplored' area of research and warned that the results should be treated with caution. The doctor added: 'However, this study shows that the chemical properties of specific substances, including heroin, should not be assumed to inevitably lead to addictive and destructive patterns of drug use. Drug research should incorporate this previously hidden population to more fully inform theory and practice. Psychological and social factors have to be taken into account when looking at how to deal with any form of addiction, including heroin addiction.'"
According to the BBC:
The study is to be published in the British Journal of Health Psychology.
The politics.co.uk website features an excellent discussion of this report as an "Issue of the Day: Evidence For Controlled Heroin Use?".
A program established in Scotland to help former addicts stay in control when released from prison has come under attack. The Herald reported on July 1, 2002 ( "Prison Policy 'Surrender To Drugs Crisis') that "The Scottish Executive has said that a handful of 'totally chaotic' prisoners are offered a heroin substitute to prevent them from overdosing or reoffending when released. Richard Simpson, deputy health minister, yesterday defended the scheme, which he said was aimed at preventing people from dying. However, Bill Aitken, the Tory justice spokesman, attacked the scheme as being 'total and abject surrender' to the drugs crisis. Three out of every four prisoners enter jail with some kind of drug problem, and 15 drug addicts died within two weeks of being released from jail in 1999."
According to the Herald, "The Scottish Prison Service introduced the controversial scheme, called the Retox Programme, earlier this year to prevent the growing number of released prisoners overdosing on heroin while on parole. Inmates are assessed by psychologists and drug counsellors, and are offered a place on the programme if it is thought there is a strong possibility they will return to drugs when released." The Herald reports that "Vic Walker, of the Open Door Trust, a charity that works with people affected by unemployment, drugs, alcohol and crime, said yesterday: 'I think there is a place ( for re-toxification ) within an overall strategy, but . . . should always be seen as a stepping stone to get people to the ultimate destination of being able to be free to reach their potential.'"
The Herald notes that "Dr Simpson stressed that the re-tox programme applied to 'a group of totally chaotic people who repeatedly, in going out of prison, have risked their lives by taking quantities of hard drugs. If we can stop them from dying, this is a measure we are prepared to take.' He said the alternative was for people to come out of jail and commit crimes for drug money. 'There are 7500 prisoners entering treatment systems and only a handful in re-toxification. This must be kept in total perspective,' he said."
The Baltimore County Council passed a resolution in mid-April 2002 that attempts to ban new methadone clinics in the county. The Baltimore Sun reported on April 22, 2002 ( "Clinics Foresee Legal Battles") that "By passing a zoning law, the Baltimore County Council has tried again to restrict where private methadone clinics can operate and sidestep the community uproar that often accompanies such facilities. But as the owners of two clinics prepare to challenge the law in court, it appears that the longstanding fight is far from over."
The Sun reports that "treatment advocates contend that the law violates the federal court order. Mid-Atlantic Realty Trust, which rents 100,000 square feet of space in the county to medical facilities, some of which would be subject to the restrictions, also has objected to the law. 'We'll go to court with it,' said Chip Silverman, a consultant for START Inc. ( Success Through Acceptable Rehabilitation Treatment ), which wants to open a clinic in Pikesville. 'We think it is definitely in violation of the Americans with Disabilities Act. We don't really see much difference between what the county has done here and what they did in the case several years ago.'"
According to the Sun, the sponsor of the clinic ban legislation, Councilman Kevin Kamenetz (D-Pikesville-Randallstown) "said he isn't opposed to methadone clinics but thinks their locations should be regulated. He says he took the same approach with legislation on pawnshops and kennels. 'There has to be some sensitivity,' he said. 'The operators of these businesses have to put themselves in the shoes of the people who live next to these businesses. Would they want to live there?'"
The Sun story noted that "According to the Maryland Department of Health and Mental Hygiene, 14 methadone clinics operate in Baltimore City, four in Anne Arundel County and one each in Howard, Carroll, Harford and Baltimore counties. The Baltimore County clinic, a public-private hybrid, is in an industrial zone off York Road in Timonium, south of the Maryland State Fairgrounds. It can serve 647 people and at last count had 534 clients, Gimbel said." In addition, "The 11 city-run clinics are augmented by three privately operated programs. But Gimbel said he's wary of private, for-profit centers because they are not required to treat people who can't pay. Private methadone treatment costs $70 a week or more. Publicly funded programs charge on a sliding scale based on income and cannot refuse treatment."
Additionally, "Dr. Peter L. Beilenson, the city's health commissioner, said he cannot believe only 534 people in Baltimore County could benefit from methadone treatment. The 11 city-run clinics have 4,451 slots, and not a day goes by that they aren't all full, he said. Official statistics show that 13 percent of the clients are from outside the city, but Beilenson said he suspects that many people give the address of a relative who lives in the city instead of their own. When Mayor Martin O'Malley told police Commissioner Edward T. Norris to clean up a handful of the worst drug corners in the city, 50 percent to 75 percent of the people caught trying to buy drugs came from the suburbs, the bulk of them from Baltimore County, Beilenson said."
Victims of Hepatitis C who are receiving methadone maintenance treatment may have to forego treatment for HCV if they wish to remain in MMT. The Journal of the American Medical Association recently reported that "Some former addicts who develop HCV-related liver disease -- notably those receiving methadone maintenance therapy (MMT) -- are confronted with barriers to getting much-needed treatment for their illness, barriers that sometimes force them to choose between dying of liver disease and risking relapse and a return to abusing drugs."
The United Nations recently issued the Report of the International Narcotics Control Board for 2000. The INCB report was quite critical of Australia's policies allowing states to set up legal heroin injection rooms. Recently, it was reported that "Victoria is likely to have a heroin trial if there is a change of leadership in Canberra this year, according to an expert who is about to take a senior role in the Bracks Government's battle against drug abuse."
The Sydney Morning Herald reported on March 7, 2001, that the Director of Public Prosecutions for New South Wales, Nicholas Cowdery, "says doctors should be allowed to prescribe free heroin. According to the Morning Herald, Mr. Cowdery said: "This would be a policy of openness and confrontation: getting the problem out in the open and confronting it together."
Switzerland provides legal heroin-assisted treatment for hardcore users. Swiss voters in 1999 approved a measure allowing state distribution of heroin to addicts. According to a publication from the Swiss Federal Office of Public Health (SFOPH), this vote means that the heroin prescription scheme will be in effect until December 31, 2004.
According to the SFOPH's "The Swiss Drug Policy," the prescription of narcotics is strictly limited to "a clearly limited group of severely addicted drug users in specialized treatment centers (criteria for admission: heroin addiction for a minimum of two years, more than 18 years old, at leaset two relapses to drug use after failures in out- or in-patient treatment and obvious adverse effects of drug use on health and/or social relations)."
(The SFOPH has on its website the abstracts from the International Symposium on Heroin-Assisted Treatment for Dependent Drug Users: State of the Art and New Research Perspectives, held March 10-12, 1999, in Bern, Switzerland.)
Click here for more news on Heroin and Methadone Maintenance Treatment as well as links to journal articles and additional information.
Organizations working on AIDS, needle exchange and methadone
This book by Andrew J. Byrne, MD, helps people learn how to cope with having an Addict In The Family. The book is free on the web, and printed copies may be purchased by mailing in the order form available here (sorry, online order-taking has not yet been arranged).
For more general information on heroin, check out Drug War Facts: Heroin.
For general information on Methadone Maintenance Treatment, see Drug War Facts: Methadone Maintenance, LAAM and Buprenorphine.