Addicts who smoke hard drugs will have an indoor place to get their fix if a Vancouver drug users group is able to open North America's first safe inhalation site later this year....
Such an unsanctioned facility would provide a supervised location for addicts to smoke crack cocaine and heroin, in much the same way that Insite -- Vancouver's legally sanctioned three-year-old safe injection site -- provides services to addicts who inject the same drugs.
PBS's series NOW had a segment on a housing first approach with a man named Footie who is chronically homeless and an alcoholic. He's clearly a late stage alcoholic, frequently has seizures and may have some cognitive impairment due to years of heavy drinking and seizures. (Streaming video of the entire episode is available at the link above.)Vancouver Mayor Sam Sullivan is lobbying the federal government for an exemption from Canada's narcotics laws that would allow what he calls a "revolutionary" alternative drug-treatment plan to give substitute drugs to at least 700 cocaine and crystal-meth addicts.
If he is successful, Vancouver would be a global pioneer in running such a large-scale program of drug maintenance for stimulant-drug users.
Sullivan said the drug plan, along with three other key elements that have to come from Ottawa or Victoria, will eliminate most of Vancouver's problems with homelessness, panhandling and drug-dealing. Those are the three social problems he promised to reduce by half in time for 2010 in the Project Civil City initiative that he launched in November.
The new law includes $10 million to expand drug-treatment options for needle exchange participants.
What are the policy implications? The author discusses the stage-specific limitations and strengths of several approaches:Drug researchers have long understood that there can be long-term waves of greater and lesser drug use and that upswings can involve epidemic-like spread. These and other dynamics discussed below imply that policy ought to vary over the course of a drug use cycle, but drug policy debates have not yet internalized this perspective.
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Because drug problems vary in these complex ways, it seems plausible that drug policy should vary over time as well; yet it is rare to hear someone couch their drug policy recommendations in these terms. This is striking and more than a little troubling. It suggests that the mental models guiding policy discussions implicitly superimpose a static framework on an intrinsically dynamic phenomenon, akin to popular nostrums for get-rich-quick investing that never vary even as economic conditions change over the business cycle.
It is not clear why policy is not discussed more often in dynamic terms. Perhaps disciplinary boundaries and stove-piped bureaucracies create single-issue advocacy. Perhaps both the health and criminal justice perspectives favour individual-level analyses. Whatever the reasons for their absence to date, dynamic perspectives on drug policy are, in fact, possible.
I'm not sure I agree with the author's assumptions about the strengths and limitations of he various approaches, but he makes a compelling argument:Preventing an initiation in the early stages of an epidemic is tremendously valuable, because it short-circuits a chain reaction that would have involved many people. (In technical terms, the reproductive rate at that point would have been large.) However, primary prevention cannot be timed to react to a burgeoning epidemic because of intrinsic lags. For example, the median age of cocaine initiation in the US is 21 years, but students in school-based prevention programmes are younger, often only 13 years old. Therefore, if school-based prevention interventions were to have any hope of affecting cocaine initiation dramatically, the ideal time to have run them would have been in the early 1970s, 8 years before the peak in initiation. However, no one knew in 1970 that there was a cocaine epidemic brewing. Conversely, the vast majority of cocaine consumed from 1985 to 2005 was consumed by people who were already older than 13 years in 1985. For instance, over 85% of people the Treatment Episode Data Set (TEDS) records as receiving treatment for cocaine between 1992 and 2003 were born before 1973. Consequently, prevention programmes initiated around the time the cocaine epidemic became salient could not possibly have had a dramatic effect on use over the next generation, regardless of how effective they were.
Treatment also has limited ability to stave off a burgeoning epidemic, because early in the epidemic most users do not have a treatable medical condition. Precise estimates are not available because population-level estimates of treatment need exist only for recent years, but need for treatment is correlated with average duration of use. In 2003, 39% of respondents reporting past-year cocaine use to the US Household Survey had been using for 10 or more years. In 1979, the peak year for cocaine initiation, that proportion was just 3%. For drugs that are not injected, the role of harm reduction strategies is similarly limited when most users are not experiencing significant harms with their use.
Enforcement's effectiveness at suppressing drug use declines markedly as the size of a drug market grows. However, enforcement has unique ability to focus its effects in both space and time. If a crack house opened next door, neither funding school-based prevention nor additional treatment slots would bring rapid relief. Parking a patrol car in front of the crack house would at least displace the activity. Similarly, assume treatment was five times more cost effective than incarceration at reducing drug use. Incarceration could still be twice as cost effective at reducing drug use this year—because incarceration's effects on drug use are concentrated in the present whereas treatment's effects may be spread over a decade or more. Hence, these models suggest that supply control programmes may have a unique capacity to disrupt the contagious spread of a new drug, but limited ability to eradicate established markets. (Enforcement may also be able to displace established markets into less destructive forms, such as forcing visible street dealing to convert to discreet meetings arranged by cell phone.)
Harm reduction offers particular advantages later in the epidemic cycle, when use has stabilized at high endemic levels. For injectable drugs in countries with low violence and few street markets, harm reduction may focus on syringe exchange programmes, supervised injection rooms and training ambulance crews to treat overdose. For drugs that are not injected and which are supplied through violent street markets, harm reduction may focus instead on using enforcement to target the minority of dealers who cause the greatest social harm. In either case the premise is that, with or without the harm reduction, the flow of new people into problem drug use will be modest, so reducing harmfulness of drug use has few drawbacks. That may not be a safe premise early in an epidemic, when there are feedbacks that can amplify small shocks to the system into dramatic effects on its trajectory.
Of course we should try to get drug addicts off their drugs. It is good that waiting times are now shorter for rehabilitation. But treatment doesn’t work unless users really, really want to give up. And even then, they often relapse because the cravings are so strong. So it is not surprising that enforced treatment and rehabilitation is so unsuccessful. A National Audit Office report on the Government’s Drug Treatment and Testing Order, a court-administered mandatory programme for addicts, found that 80 per cent of offenders were reconvicted within two years.
It is much more sensible to prescribe a maintenance dose for addicts, which they must take under supervision so they cannot sell it on, until they are ready to try to give up. That way, they can attempt to lead a normal life, to refrain from crime, to stay off the streets, even to hold down a job, until they can wean themselves off the drugs.
Among the flawed assumptions are that:
John Grabowski, from the University of Texas, will be the keynote speaker at a conference in Sydney today on ice use.
Speed, or dex-amphetamine sulphate, poses a high risk of dependency and abuse.
The conference has been called by the NSW Government and is being attended by government representatives from around Australia and international experts.
Dr Grabowski said one of the most promising treatments for ice, or meth-amphetamine - associated with intense violent and psychotic episodes among habitual users - was the drug commonly known as speed. He said dex-amphetamine was already widely used for the treatment of Attention Deficit Disorder and research suggested it could stabilise Ice users.
Dr Grabowksi said that while there were political difficulties in using a legal form of a drug to combat its illegal use, research was showing sufficiently positive results to move forward. Just as methadone, a form of opiate, was used for the treatment of heroin addiction, so the use of speed may become acceptable for the treatment of Ice addiction.
He said there was probably no other way to deal with some hard-core users creating problems for police and hospitals. "There is a population for which I don't see any good alternative," he said.
A safe injection center in Australia is experiencing unanticipated problems with meth addicts:
Injecting centre medical director Ingrid van Beek said eight per cent of the 220 addicts using the centre each day were injecting ice - more than twice the number 18 months ago.
"Ice changes people's behaviour in such a dramatic way and can be quite scary,'' she said. '
"People become incredibly strong and quite aggressive, and that's what makes the impact of this drug greater.''
Staff had undergone additional training to manage abusive behaviour among ice addicts and to identify the early signs of psychosis, Ms van Beek said.
"Staff have to be aware of how to manage that sort of crisis situation, and our staff are specially trained in that.''
Ms van Beek said that if people showed sings of emerging psychosis, they were counselled and not allowed to enter the centre.
The Sunday Telegraph approached several addicts outside the injecting centre who admitted to using ice inside.
One man said staff did not check the type of drug he injected.
"I just don't tell them. They don't care; they just write you down on a piece of paper,'' he said.
"You just say, `I'm doing hammer (heroin)' and go boom, boom quickly. Just keep it quiet.''
Another addict, calling himself Ace, said: "Hell yeah, bro, it's a proper sealed joint in there with security guards and all. You can do what you want.
"It's amnesty once you cross the door; cops can't touch you.''
A security guard at the Mansions nightclub, across the road, said ice users were often seen stumbling on to the street, drug-fuelled and aggressive.
"They must be on ice - they're screaming and ranting and raving,'' he said.
