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Heroin users, Prohibitionists, Critics and Enablers

Mark Kleiman points to an excellent NPR story about an incredible, easy-to-use nasal spray that can save lives when applied quickly after a heroin overdose.

The nasal spray is a drug called naloxone, or Narcan. It blocks the brain receptors that heroin activates, instantly reversing an overdose.
Doctors and emergency medical technicians have used Narcan for years in hospitals and ambulances. But it doesn’t require much training because it’s impossible to overdose on Narcan.

Studies have showed the benefit and safety of its use and many lives have been saved. The ONDCP, however, has, of course, objected to making Narcan available to heroin users.

Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy, opposes the use of Narcan in overdose-rescue programs.
“First of all, I don’t agree with giving an opioid antidote to non-medical professionals. That’s No. 1,” she says. “I just don’t think that’s good public health policy.”
Madras says drug users aren’t likely to be competent to deal with an overdose emergency. More importantly, she says, Narcan kits may actually encourage drug abusers to keep using heroin because they know overdosing isn’t as likely.

Mark Kleiman correctly notes the moral depravity of the ONDCP’s stance:

The Office of National Drug Control Policy is working hard to make sure that opiate addicts keep dying of overdoses. […]
Why not just go all the way and poison the heroin supply? If withholding Narcan in order to generate more overdoses in order to scare addicts into quitting were proposed as an experiment, it could never get past human-subjects review. But since it’s a failure to act rather than an action, there’s no rule to require that it be even vaguely rational.

Absolutely. So far, so good, for Kleiman. But then, as usual, he has to drop all pretense of academic integrity and retreat into his pathetic pseudoskeptic persona with this bizarre backhanded compliment:

I get angry at the people who call themselves the “drug policy reform movement” for their insistence that we could make more drugs legal without having more addiction. But unlike their counterparts in the equally reality-challenged but politically dominant “drug-free America” movement, the “drug policy reformers” lack the power to kill in the service of their dreams.

Note the use of the belittling “who call themselves” generalization. Once again, Mark takes a perfectly good post about the problems with drug warriors, and for no good reason (and no relevance to the post), slams reformers. And, as usual, mischaracterizes the arguments of reformers.
Yes, some drug policy reformers (myself included) believe that, while drug use may go up in a legalization scenario, it is likely that abuse of drugs will remain relatively the same or even go down. This is supported by the fact that legalization would provide implementation of better regulation, more focus on treatment, safer drugs, increased likelihood of seeking help, substitution of one drug for another, reduction of black market methods, and more societal focus on problem drug abusers rather than diluting efforts by going after all drug users. These are real, legitimate arguments that can’t be dismissed by Mark’s patently absurd view that the numbers of those who abuse legal alcohol can be used to project how every legal drug will be abused.
However, the even more important (and relevant) view that pretty much all drug policy reformers hold is that the overall harms related to drugs and drug prohibition will be greatly reduced under a regulated legal market compared to a prohibition-fueled black market regime. This can’t be refuted.
[Interestingly, Kevin Drum picks up the story, in an passing post about the ONDCP’s view, but his readers also catch the rest of it pretty well in comments (Kleiman’s site no longer accepts comments).]
Kleiman’s off-handed non-critique as usual fails to deal with the fact that legalization and regulation can mean a whole lot of different kinds of options. Mark seems to intellectually know this, as he will go on ad nauseam on a wide variety of bizarre regulatory schemes (see drinking licenses) in this books and writings, yet not apply time-tested regulatory approaches when calculating the cost/benefit ratio of prohibition versus legalization. For that matter, he doesn’t even like making that calculation, because that would give legitimacy to the thought of legalization.
OK, Mark — you want to talk policies? Specific policies?
Let’s talk about a legalization approach to heroin, since that’s the subject of this post — heroin maintenance. Have the government provide safe controlled doses of heroin to all those who are dependent on heroin. Heck, make it free of charge (you could easily to so by buying cheap heroin in Afghanistan and because of the the enormous savings from reduced health care, enforcement, and prison costs).
Would this work? Yes. Would it, in fact, reduce the rate of heroin addiction? Yes. How do we know? Because the Swiss have been doing it for years. No, they weren’t able to do it in full scale as a complete legalization approach due to pressure from the U.S., but they were able to do it in a significant sample of the most hard-core heroin users (whom most would agree are the true problem group). This is something I’ve talked about before, but I’ve been hoping for updated information on the Swiss approach.
Fortunately, LEAP’s Howard Wooldridge has done a tremendous service by putting together Swiss Heroin-Assisted Treatment 1994-2008: Summary, which has been approved by the Swiss Federal Office of Public Health. It’s worth printing here in full:

Overview: Due to the severe drug problem in Switzerland in the early 1990s, (rising number of injection drug users, visibility of open drug scenes, AIDS epidemic, rising number of drug related deaths, poor physical health, high criminality) the Swiss made a fundamental shift in approaching the problems caused by heroin addiction. The Swiss offer treatment-on-demand. Of an estimated 22,000 addicts, 16,500 are in treatment and 92% are given daily doses of methadone at conventional clinics. The Swiss treat about 1300 addicts with maintenance doses of heroin via 23 special clinics operating in cities and two prisons. The Swiss approach has resulted in lower rates of crime, death, disease, a drop in expected new users as well as an improvement in mental and physical health, employment and housing. The program has been copied by six countries: Germany, Holland, Belgium, England, Spain and Canada.
* To qualify for a heroin prescription: 1) at least 18 years old; 2) been addicted (daily use) for at least two years; 3) present signs of poor health; 4) two or more failed attempts of conventional treatment (methadone or other); 5) Surrender drivers license; 6) Heroin can only be obtained at the clinic and must be consumed on site (oral or injection). (Note: Under strict control and specific criteria [for example full employment] a few are allowed to take one oral dose daily away)

  1. Patients can receive up to three doses of heroin per day. 60% take the heroin via needle injection, the rest via pill. The use of the oral pill is increasing.
  2. Patients average about three (3) years in this plan. However, they may stay in treatment indefinitely. 20% of original patients are still in the program.
  3. The vast majority of patients are satisfied or very satisfied with the program.
  4. Average age of patient: 38 years.

*Crime Issues: 60% drop in felony crimes by patients. 82% drop in patients selling heroin.
*Death Rates: No one has died from a heroin overdose since the inception of the program. The heroin used is inspected for purity and strength by technicians.
*Disease Rates: New infections of Hepatitis and HIV have been reduced for patients in the program.
*New Use Rates: Lower than expected.

  1. As reported in the Lancet June 3, 2006, the medicalisation of using heroin has tarnished the image of heroin and made it unattractive to young people.
  2. Most new users are introduced to heroin by members of their social group and 50% of users also deal to support their habit. Therefore, with so many users/sellers in treatment, non-users have fewer opportunities to be exposed to heroin, especially in the rural areas.

*Cost Issues: 48 dollars/day: Patients pay from zero to 12 dollars per day depending on their ability. Note: About 30% of patients work for a living and pay part of the costs. Note: The Swiss save about 30 dollars per day per patient mostly in lowered costs for court and police time, due to less crime committed by the patients.
** This summary was taken from five published reports. The Swiss Federal Office of Public Health reviewed and approved its release. Additional questions should be directed to Dr. Dora Fitzli, the science and health advisor to the Swiss Ambassador at the Embassy. Her English is near native fluency.
NOTE: This summary was researched and written by Howard J. Wooldridge of LEAP.

Prohibitionists and prohibitionist enablers don’t want to believe that any form of legalization can work. They firmly believe that problem users won’t quit unless they are coerced, and so they mindlessly support prohibition. Even if that were true (and the evidence isn’t clear that coercion works better overall), it would be better to live with a group of well-managed hard-core drug users than to continue the massive evils resulting from prohibition.

[Note: Other examples of Kleiman’s approach are here, here, here, here, here, here, …]
[Update: a couple of small editorial changes made to improve reading flow.]

Update: Ethan Brown notices Kleimans’s problem as well.

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