COMMENTARY: OPIATES FOR THE MASSES

One hundred years ago, German chemists introduced heroin to the world. On
Saturday the New York Academy of Medicine held a conference celebrating the
drug's latest use, "heroin maintenance": medically supervised distribution
of pure heroin to addicts. The academy's First International Conference on
Heroin Maintenance introduces to our shores the latest example of the
pernicious drug-treatment philosophy known as "harm reduction."

Harm reduction holds that drug abuse is inevitable, so society should try
to minimize the damage done to addicts by drugs (disease, overdose) and to
society by addicts (crime, health care costs). According to the Oakland,
Calif.-based Harm Reduction Coalition, harm reduction "meets users where
they are at . . . accepting for better or worse, that drug use is part of
our world."

Its advocates present harm reduction as a rational compromise between the
alleged futility of the drug war and the extremism of outright
legalization. But since harm reduction makes no demands on addicts, it
consigns them to their addiction, aiming only to allow them to destroy
themselves in relative "safety"--and at taxpayer expense.

Specious Choice

The recent debate over needle exchange illuminates the political strategy
of harm reductionists. First, present the public with a specious choice:
Should a drug addict shoot up with a clean needle or a dirty one?
(Unquestioned is the assumption that he should shoot up at all.) Then
misrepresent the science as Health and Human Services Secretary Donna
Shalala did when she pronounced "airtight" the evidence that needle
exchange reduces the rate of HIV transmission. In fact, most needle
exchange studies have been full of design errors; the more rigorous ones
have actually shown an increase in HIV infection.

And so it is with heroin maintenance. First, the false dichotomies: pure
vs. contaminated heroin; addicts who commit crime to support their habit
vs. addicts who don't. Then the distortion of evidence. The Lindesmith
Center, one of the conference sponsors, claims that "a landmark Swiss study
has successfully maintained heroin addicts on injectable heroin for almost
two years, with dramatic reductions in illicit drug use and criminal
activity as well as greatly improved health and social adjustment."

In fact, the Swiss "experiment," conducted by the Federal Office of Public
Health from 1994 to 1996, was not very scientific. Addicts in the 18-month
study were expected to inject themselves with heroin under sterile
conditions at the clinic three times a day. They also received extensive
counseling, psychiatric services and social assistance (welfare, subsidized
jobs, public housing and medical care). Results: The proportion of
individuals claiming they supported themselves with illegal income dropped
to 10% from 70%; homelessness fell to 1% from 12%. Permanent employment
rose to 32% from 14%, but welfare dependency also rose to 27% from 18%. The
rate of reported cocaine use among the heroin addicts dropped to 52% from
82%.

These numbers may look promising, but it's hard to know what they mean.
Verification of self-reported improvement was spotty at best. And addicts
received so many social services--five times more money was spent on them
than is the norm in standard treatment--that heroin maintenance itself may
have played no role in any overall improvement.

Definitions of success were loose as well. Anyone who kept attending the
program, even intermittently, was considered "retained." By this standard,
more than two-thirds made it through--a much higher retention rate than in
conventional treatment. But considering that the program gave addicts
pharmaceutical-grade heroin at little or no cost, it's astonishing that the
numbers weren't higher. It turned out that the patients who dropped out
were those with the most serious addiction-related problems--those who had
been addicted the longest, were the heaviest cocaine users, or had HIV--the
very groups that are of the greatest public-health concern.

What's more, the researchers did not compare heroin maintenance with
conventional treatments such as methadone or residential,
abstinence-oriented care. They abandoned their original plan to assign
patients randomly to heroin maintenance or conventional methadone--because,
among other reasons, the subjects, not surprisingly, strongly preferred
heroin.

"The risk of heroin maintenance is the incentive it provides to 'fail' in
other forms of treatment in order to become a publicly supported addict,"
says Mark Kleiman of UCLA School of Public Policy. And in fact, once the
heroin maintenance project started, conventional treatment facilities
reported a sharp decline in applications, even though the rate of drug use
remained steady.

The Swiss heroin experiment was born out of desperation. In the mid-1980s,
the Swiss government became disenchanted with drug treatment and turned to
a policy of sanctioned drug use in designated open areas. But this was
unsuccessful; the most visible failures being the squalid deterioration of
Zurich's Platzspitz Park (the notorious "Needle Park") and the
syringe-littered Letten railway station.

It is telling that harm reduction efforts have evolved in countries that
provide addicts with a wide array of government benefits. Rather than throw
up their hands at the poor record of drug rehabilitation, the Swiss and
others should acknowledge the extent to which welfare services enable
addiction by shielding addicts from the consequences of their actions,
financing their drug purchases and encouraging dependency on public
largesse.

Nonetheless, Switzerland has ardently embraced heroin maintenance. The
Federal Office of Public Health plans to triple enrollment next year to
about 3,000; and in 2004 the Swiss Parliament plans to decriminalize
consumption, possession and sale of narcotics for personal use.

Not everyone shares Bern's enthusiasm. Wayne Hall of Australia's University
of New South Wales was an independent evaluator for the World Health
Organization who assessed the experimental plan of the Swiss project. "The
unique political context . . . of the trials . . . meant that opportunities
were lost for a more rigorous evaluation," he wrote. In February, the
International Narcotics Control Board of the United Nations--a
quasijudicial body that monitors international drug treaties--expressed
concern that "before [completion of] the evaluation by the World Health
Organization of the Swiss heroin experiment, pressure groups and some
politicians are already promoting the expansion of such programmes in
Switzerland and their proliferation in other countries."

And indeed, the trials' principal investigator and project directors have
traveled to Australia, Austria, Germany, the Netherlands and elsewhere
promoting heroin maintenance. They won a sympathetic hearing in the
Netherlands, which plans to begin a heroin experiment next month. This
isn't surprising; after all, this is a country that has a union for
addicts, the Federation of Dutch Junkie Leagues, which lobbies the
government for services. In Rotterdam last month, I visited a Dutch
Reformed church where the pastor had invited two dealers in to sell
discounted heroin and cocaine. He also provided basement rooms where users
could inject or smoke heroin.

Nothing in Return

Even if heroin maintenance "worked"--if it could be proved that heroin
giveaways enhanced the addicts' health and productivity--we would still
have to confront the raw truth about harm reduction. It is the
public-policy manifestation of the addict's dearest wish: to use free drugs
without consequence. Imagine extending this model--the use of
state-subsidized drugs, the offer of endless social services and the
expectation of nothing in return--to America's hard-core addicts.

Today the U.N. General Assembly opens a special session on global
drug-control policy. Harm reduction advocates will tell the world body that
drug abuse is a human right and that the only compassionate response is to
make it safer to be an addict. The Swiss and the Dutch seem to view addicts
as irascible children who should be indulged, or as terminally ill patients
to be palliated, hidden away and written off. But heroin maintenance is
wrong. As an experiment, thus far it is scientifically groundless. As
public-health policy it will always be a posture of surrender.

Checked-by: (Joel W. Johnson)