A PRESCRIPTION FOR PEACE

"Patriots Don't Use Heroin," was the headline on a recent column in the
Cincinnati Post, discussing the creation of a new anti-drug task force by
the House. As Ohio Congressman Bob Portman, one of three co-chairs of the
committee put it, "By Americans spending money on their drug habits, we are
helping to support the Taliban government, which protects terrorism."

Or, as the Post's Washington Bureau chief Michael Collins wrote: "Real
Americans don't do drugs." Leaving aside the questionable truth of that
assertion -- 50 percent of us are physically dependent on caffeine, over
half of adults have tried marijuana, 29 percent smoke cigarettes and half
the population drinks alcohol regularly-- there certainly is something to
the idea that black market drugs fuel large criminal organizations,
including some that sponsor terrorism.

But calling on the patriotic fervor of deeply-troubled heroin addicts --
who are hard-pressed to stop to avoid losing their relationships with loved
ones or even to avoid prison -- is unlikely to get many to quit. And worse,
demonizing addicts creates an atmosphere which tends to preclude offering
them the best treatment -- one of the few real and politically viable ways
to shrink drug demand and the profits of criminals who benefit from it.

The State Department estimates that 72 percent of the world's heroin supply
originates in Afghanistan. Unlike with cocaine, however, the West has a
great weapon for fighting opiate addiction.

Maintenance prescribing -- whether of heroin itself or of substitutes like
methadone -- can be dramatically effective at reducing crime and returning
addicts to productive lives.

For example, data from DATOS, the most recent major national treatment
outcome study funded by the National Institute on Drug Abuse, shows a 64
percent drop in weekly or more frequent heroin use and a 48 percent drop in
cocaine use after one year of methadone treatment.

Illegal activity fell 52 percent. Compared to other types of treatment,
methadone has been shown to be most effective for heroin addicts.

And given in a steady dose, opiates like methadone do not impair addicts
mentally, emotionally or physically: the worst side effect is constipation.

Between 1994 and 1996, the Swiss government conducted a study of another
form of maintenance: providing heroin itself to addicts.

Following over 1000 participants, who were amongst the most impaired heroin
addicts in the country, researchers found that after 18 months of
treatment, only 5 percent of patients were using cocaine in addition to
their licit heroin and 9 percent were using illicit benzodiazepines. Rates
of permanent employment doubled-- and 1/3 of those who started on welfare
did not require benefits after 18 months.

The number of criminal offenses committed by those in treatment dropped 60
percent during the first six months alone.

With those kinds of numbers, rapidly expanded maintenance prescribing could
dramatically affect drug markets.

But in order to work, such prescribing must be done right -- and in the
right places.

Current U.S. and European regimes tend to stress avoiding diversion of
drugs from patients into a "grey" market -- often at the cost of making
barriers to treatment high and treatment itself a limit on freedom (You
can't travel, for example, if you have to appear at a clinic every day at a
certain time to get your drugs). As the Institute of Medicine put it in a
1995 review of the methadone regulations, "Current policy...puts too much
emphasis on protecting society from methadone, and not enough on protecting
society from the epidemics of addiction, violence, and infectious diseases
that methadone can help reduce."

These priorities need to be reversed.

Methadone should be made available with as few restrictions as possible to
anyone who can show that he or she is physically dependent on opiates.

Though federal regulations were recently loosened to some extent, the drug
is still the most regulated substance in the American pharmacopeia and only
about 10-20 percent of heroin addicts have access to it.

Diversion might even be seen as a secondary goal of such treatment.

With methadone, diversion has little chance of spreading addiction to new
users -- buyers of "street" methadone are almost always addicts who aren't
in treatment, but want a break from heroin without bureaucratic hassles.

Even with the most liberal prescribing practices, there will always be some
who resist professional help. But if this group buys diverted methadone,
that's money not spent on black market heroin.

If we were to try heroin prescribing, controls might need to be tighter--
but even if there is some diversion, this, too, is competition for the
black market and at least diverted legal drugs start pure and in known
quantities.

Expanded treatment could involve things like the use of "methadone buses"
to keep NIMBY problems at bay, as has been done in Amsterdam. Regular
doctors (not just the current specialized clinics) could be urged to
prescribe methadone which would be obtained like any other prescription at
a pharmacy-- something which is legal in the U.S. for the first time in
decades under the new regulations.

Sadly for the rhetoric of anti-drug Republicans, only 5 percent of
Afghanistan's heroin makes its way to America., according to the State
Department. This means that our junkies couldn't do much for the war effort
simply by kicking even if they wanted to -- but it doesn't mean that we
shouldn't try to improve treatment by improving access to care and cutting
crime, prison costs, AIDS and other blood borne infections, etc.

Europe, however, could make a real difference. About half of Afghanistani
heroin goes to Europe according to the U.N. and experts estimate that close
to 100 percent of heroin used in the U.K. comes from that country.

Since the U.K. and many other European countries are already looking to
reform ineffective and burdensome drug laws, this change may be politically
possible there as well. The U.K., for example, already permits heroin
prescribing and pharmacy pick-up of methadone.

As Peter McDermott, one of the directors of the UK Harm Reduction Alliance
put it after introducing this idea to treatment providers in England on the
group's internet list, "Perhaps we should start to regard over-prescribing
and the encouragement of the gray market as a blow for world peace?"