CONTROVERSIAL SOLUTIONS ARE BETTER THAN NONE

The Scourge Of Crack Cocaine Is Not Being Addressed By Mythical
Treatment Programs. So What Is Out There Now

If it were any other social problem that causes billions of dollars in
health care costs, policing and property damage, Canadians would be
demanding that governments do everything -- or at least everything
that science suggests will help -- to reduce or eliminate the problem.

Alas, the problem is drugs. More specifically, that nastiest and most
nefarious of drugs -- crack cocaine. Any controversial attempt to
reduce the tremendous damage caused by crack addiction is invariably
met by howls of outrage from those who supposedly know better.

So it was with the recent announcement that the B.C. Ministry of
Health plans to distribute crack pipe components, such as mouthpieces
and filters, to addicts on Vancouver Island.

This is hardly earth-shattering news, since "safer use crack kits"
have been distributed in many Canadian cities, including Toronto,
Winnipeg, Ottawa, Halifax, Gatineau, Montreal and Guelph.

Nevertheless, almost before the ministry announced its plans, the
critics descended, accusing the ministry of promoting, or at least
facilitating, crack use.

Yet crack use needs no facilitation: Addicts will get their drugs --
must get their drugs -- regardless of how difficult it is.

Others dismissed a recent study by Benedikt Fischer of the University
of Victoria's Centre for Addiction Research, which suggested that
sharing crack pipes might lead to transmission of the Hepatitis C
virus (HCV).

Now, I'll be the first to admit -- or the second, after Fischer
himself -- that we have no proof that sharing crack pipes contributes
to the transmission of HCV. Fischer studied 51 crack smokers and found
HCV on one pipe, which doesn't prove that sharing pipes leads to HCV
transmission.

But it certainly suggests that fears of transmission are not
unfounded, and the pennies it costs to provide addicts with clean
mouthpieces seems a good investment given the enormous costs
associated with treating HCV infection.

Undeterred, critics argue that addicts ought to be directed toward
treatment instead of permitting them to continue using.

I have two questions for these naysayers: First, exactly what
treatment do you recommend for crack addicts? Second, how exactly do
you plan to get addicts into treatment?

To take the second question first, even if there were adequate
treatment facilities for crack addicts -- which there are not --
getting people into treatment is not as simple as providing the
facilities and expecting addicts to flock to them.

Rather, people chronically addicted to illicit drugs are often unaware
of the services available; even if they are aware, they're frequently
"system shy" given that our culture views them with disdain and given
that their habit is illegal.

The Conservatives' recent proposal to impose mandatory sentences for
cocaine trafficking will only exacerbate this situation, since crack
addicts are the most likely illicit drug users to begin dealing to
gain some income.

Given the extreme marginalization of crack addicts -- Fischer refers
to them as "the marginalized among the marginalized" -- they're not
likely to enter treatment unless they're first educated about, and
develop trust in, the system.

One of the best ways to do this is through outreach, such as
distributing safer use crack kits. We have seen that attendance at
Vancouver's supervised injection site is associated with opiate users
entering into detox and treatment, and outreach to crack addicts could
have a similar effect.

Hence distributing crack kits might actually facilitate entry into
treatment, instead of facilitating drug use.

Which brings us to my second question: What treatment is available for
crack users? Sadly, not much; despite studies of some 50 drugs, there
is no established pharmacotherapy for crack addiction. Users are
therefore typically treated with psychotherapy and 12-step programs,
but these haven't proven terribly successful in reducing use or
preventing relapse.

There are, however, a couple of promising treatments. Yet both are as
controversial as distributing crack kits -- and are often opposed by
the very people who oppose crack kits -- because both involve
providing cocaine or other stimulants to addicts.

The first involves providing chronically addicted cocaine or
amphetamine users with a substitution stimulant such as
dexamphetamine. Several studies, led by James Shearer at the
University of New South Wales and John Grabowski at the University of
Texas-Houston, have found that the medical provision of dexamphetamine
has resulted in a reduction of the severity of cocaine dependence and
therefore of cocaine use, along with a reduction in criminal activity
by cocaine addicts.

Grabowski further discovered that subjects receiving dexamphetamine
were more likely to remain in counselling, an important finding given
that substitution treatment is not a panacea but must be accompanied
by psychotherapy.

Buoyed by this evidence, Vancouver Mayor Sam Sullivan has advocated
that Health Canada approve a research trial -- the Chronic Addiction
Substitution Treatment Trial, or CAST -- to see if stimulant
substitution treatment can help to reduce the health and public
disorder consequences of stimulant addiction and ultimately lead to
abstinence.

The second controversial intervention involves a cocaine vaccine.
While most pharmacological research aims at rewiring neural pathways
that are affected by illicit drugs, an effective vaccine would prevent
the drug from entering the brain.

Cocaine molecules are too small for the body to recognize, which means
that the body fails to produce antibodies, allowing cocaine to reach
the brain unimpeded.

But the vaccine attaches inactivated cocaine to inactivated cholera
toxin, and the immune system recognizes, and produces antibodies
against, both the cocaine and the cholera, preventing them from
crossing the blood/brain barrier. After being inoculated with the
vaccine, users don't receive a high if they smoke crack.

The vaccine has been in development for more than a decade, and
despite being attacked by people who oppose providing cocaine, even
inactive cocaine, to addicts, is now being tested in clinical trials
conducted by the husband and wife team of Tom and Therese Kosten at
the Baylor School of Medicine in Houston, Texas.

The Kostens' work, together with that of John Grabowski, reveals that,
far from being in the vanguard in the War on Drugs, the Lone Star
state has become a leader in developing innovative drug addiction
treatment. And all the while Canada plunges itself deeper into the
abyss by increasing the criminalization of drug addiction.

Anyway, if the Kostens' trials prove successful, a vaccine could be
available in three to five years. That's promising, but three to five
years can be a lifetime for crack addicts, and that, together with the
absence of effective therapies for crack addiction, means that harm
reduction efforts like distributing crack kits takes on added importance.

To be sure, crack kits aren't a complete solution to the problem of
addiction, nor are substitution treatment or anti-drug vaccines. But
it is only by keeping an open mind, rather than reflexively and
unreflectively dismissing controversial but potentially effective
interventions, that we will find the solutions for addicts, and for us
all.