THE PROMISE OF SAFER INHALATION

When Canadians think of crack cocaine, many remember disturbing
television images seen in the late 1980's, when the drug first gained
notoriety in the United States. More recently, crack has emerged as
an enormous health and social problem in many Canadian cities.

Last month, a group of Vancouver researchers published a 10-year
study from Vancouver's Downtown Eastside in the Canadian Medical
Association Journal. The study, which I led, revealed a pair of
significant findings: one, a massive increase in crack-cocaine use in
recent years, and two, daily crack users have a four-fold higher rate
of HIV infection. The study also made various recommendations to deal
with rising crack-cocaine use and the corresponding increase in HIV.

When developing rational responses to rising crack use in Canada, it
is useful to first reflect upon the long-term patterns of crack use
in the United States. South of the border, the drug's use has
remained persistently high despite an estimated $1-trillion spent on
the "war on drugs." The failure of America's over-reliance on law
enforcement is also demonstrated by increasing cocaine purity and
falling cocaine prices over the last 10 years, as well as a
ballooning prison population.

Primarily as a result of drug-law enforcement, one in eight
African-American males in the age group 25 to 29 is incarcerated on
any given day in the United States, despite the fact that ethnic
minorities consume illicit drugs at comparable rates to other
Americans. The economic forces of supply and demand have simply
overwhelmed the vast police efforts, leading Nobel-Prize-winning
economists such as Milton Friedman to recommend complete abandonment
of the drug war.

It has famously been said that doing the same experiment over and
over again and expecting different results is the very definition of
insanity. There is overwhelming consensus in the scientific community
that the U.S. approach to the control of crack cocaine has been a
disaster. Therefore, Canadians must look elsewhere for more effective
models, including Western Europe.

After successfully reducing public drug injecting, and recruiting
intravenous drug addicts into treatment through the use of supervised
injection facilities, several Western European countries have
expanded these programs to include "inhalation facilities" for heroin
and crack smokers. The philosophy is the same: Get addicts off the
street and under the public health umbrella, where addiction
treatment is available on demand.

It was in this context that we recommended an inhalation facility be
considered for scientific evaluation in Vancouver.

A subsequent National Post editorial argued that HIV infections in
Vancouver were likely due to needle-sharing and unsafe sex among
crack users, and incorrectly implied that our recommendation was
based solely on an unproven "oral-health hypothesis" whereby
inhalation rooms would possibly prevent HIV transmissions due to the
sharing of crack pipes.

First, our study clearly acknowledged that the link between HIV
infection and crack smoking was likely due to a combination of
factors. Second, with regard to needle-sharing and unsafe sex,
evaluations of supervised injecting facilities have clearly
demonstrated how these programs prevented needle-sharing and improve
rates of condom use, which is why they have been proven cost-effective.

Finally, although studies from the United States have implied that
the HIV virus may be transmitted by the sharing of crack pipes or
oral sex among individuals with cuts and burns on their lips from
crack smoking, we do not believe this is the primary reason an
inhalation room should be evaluated. A study published in the New
England Journal of Medicine demonstrated that the use of the Insite
injecting facility in Vancouver enabled more rapid uptake of
addiction treatment. A similar investigation should be the primary
aim for any clinical trial of an inhalation facility.