I will continue to enable people who inject drugs….

I actively promote the supply of sterile injecting equipment for people who inject drugs. A recent facebook comment criticised the supply of needles to people who use drugs:

This program promotes active addiction! Why does this organisation not offer addictions counselling as part of their program?
Yes I undertsand the objective is to help reduce the spread of hiv but what is being done, instead is helping these addicts use, why would they feel the need to get clean when they are enabled in using. The disease if addiction is by far more dangerous than hiv. There is no known cure. When that addict over doses with the same needle you supplied how do you sleep at night?

and was supported by a second comment:

This situation is unacceptable. Why not introduce rehabilitation programs, 12 step programs to help combat active addiction.

These are not uncommon responses. When politicians or members of the public make these comments, I make an effort to try and explain the data and the reasons why these programmes are essential. Frankly though, when people claim to have expertise in an area, yet they have not read the data, or have not critically examined what does, and does not, work, I have less patience. I am posting my lightly edited response here so I can direct future critics here.

1. The aim of any harm reduction programme should be to help people regularly make conscious, accurately informed choices about their drug use or their decision not to use, and despite their choices, to reduce the level of harms created by a prohibitionist response to drugs.

2. The program does not promote ‘active addiction’.

2.1. It does advocate for the rights of all people, including people who use drugs.

2.2. It does care more for people’s lives than for the promotion of moral opinion.

2.3. It does evaluate impact, and it does help people achieve the goal of abstinence, if that is what they choose.

2.4. It provides a commodity (needles) to people who need them, and does so through peer led teams — but those teams use the opportunity to provide other essential services to people who use drugs, who, most of the time, are denied even the most basic of services.

2.5. It does actively demonstrate that some people do care for them no matter what their choices around drug use are.

2.6. It does not refuse people the right to life just because they use certain drugs.

3. The provision of a needle is not sufficient for someone to shift from non-injecting to injecting drug use.

4. The lack of a sterile needle is not sufficient to stop someone from injecting a drug.

5. The availability of sterile needles is sufficient to:

5.1. encourage people to access and form a relationship with health and other services

5.2. Prevent abscesses, infective endocarditis and a plethora of other health issues that result NOT from injecting drugs, but from not having access to sterile needles

5.3. When combined with a package of other services, slow the spread of HIV and HCV

5.4. Assist people in evaluating their drug use and empower them to make the changes they feel they can make and are appropriate for them to make

6. The lack of sterile needles is sufficient to:

6.1. Increase needle sharing

6.2. Cause undue pain and suffering and various health impacts

6.3. Increase the incidence of HIV and HCV

6.4. Decrease the number of people who are drug dependent from getting services, including abstinence based services, should they choose this

7. In answer to your question: “why would they feel the need to get clean when they are enabled in using”, I would ask:

7.1. Why would people want to stop using drugs in a world that does not care for their basic rights or needs, judges them, excludes them and seeks to take away an effective means of dealing with the daily challenges of existence? Contrary to common belief, the dependent use of drugs in these circumstances provides significant short-term benefit in an environment where choices are limited.

7.2. Why would people claiming to want to help people, deny them a tool that we know reduces mortality and suffering?

8. People get ‘clean’ when they have access to showers, not when the stop using drugs.

9. People who use drugs are more likely to change the means, patterns and moderate drug use when they have the space, means, autonomy, respect and compassion to do so.

10. Even if addiction was a disease (something that is not supported by the majority of the data across disciplines), drug dependencies (substance use disorders in the DSM) Resolve in almost all cases; Resolve without treatment; Resolve without total abstinence, and in many cases the use of the drug considered problematic can be moderated. For the data supporting this see reference list at end.

11. Where a substance use disorder is persistent, longevity of dependence is usually linked to: A belief in the disease concept and a lack of coping skills (Miller), psycho social dislocation of some sort (Alexander, Zinberg, Siegel and Julian Buchanan etc)

12. To the question: “Why not introduce rehabilitation programs, 12 step programs to help combat active addiction.”

12.1. There are 12 step programmes. People can go anytime they want, but:

12.1.1. There is little data to support them;

12.1.2. And, while 12-step programmes help some, it is despite the 12-steps, not because of them. The active ingredient is the fellowship, structure and support. I doubt the NA Blue Book would get ethical clearance if submitted to an ethics committee today— read the opening of chapter five, as an example. It is essentially a moral treatise designed to assist self-centered, 1940/50 white male Americans and has little place in my setting– but that is a whole different discussion

12.1.3. There is not a single robust study in the world that shows that 28-day rehab is any better than spontaneous remission rates, and, there are a number (see Moose by example) that show that it is possibly iatrogenic.

YES, I do often struggle to sleep at night:

When someone overdoses, and even on the nights when no one overdoses, I can’t sleep because my head is spinning with questions like: Where was naloxone? Is there naloxone? Why the restrictions on a life-saving medication that has no psychoactive properties? Was their dose contaminated with fentanyl? Why has no one really investigated the issue of fentanyl? What if this was beer contaminated with methanol? How different wouldthe response be? Why did person who overdosed not have access to diamorphine of known concentration and purity? Why was there no one with them? Were they aware of the dangers of drug interactions?

I wonder if they had recently been told that they should stop using heroin because only then would they be worth anything, only then could they be useful, or only if ‘clean’ could they come back home and be loved.

I wonder if they had tried to stop, but believed that they had ‘a lifelong disease’ that could only be cured by stopping, which was impossible at that time. After taking the steps everyone said were essential, and after applying ‘these principles’, and failing, I wonder if they realised they would never be welcome at the table.

Perhaps they pushed the limit a bit more than before, because, hey, it would ease the suffering of their family, and at least they would go out feeling the warm blanket of heroin around their heart, and who would miss another ‘junky’.

And lie awake and wonder if they had just gone through the thing that significantly increases the risk of death for heroin dependent people — abstinence based treatment (yes, go read the data).

The only way I can sleep is to do that thing that many ‘addiction specialists’ tell everyone not to do, and try to prevent the thing they say must happen. I will ‘enable’ people who use drugs and I will not standby and passively let them ‘hit rock’ bottom.

I will enable them to reduce risk, to inject without increased risk, I will enable them to improve their lives and exercise autonomy, whether they keep on using drugs or not. I will reduce the burden of prohibition wherever possible. I will put whatever actual or metaphorical safety nets are needed to cushion their fall. I will repeatedly throw life-lines. If I have the resources I would pay bail and for lawyers. I will give agonists and needles, and, when possible, food and shelter, employment and money.

I will never practice tough love. I will just love.

References:

Alexander, B. (2008). The Globalisation of Addiction: A study in the poverty of spirit. Oxford: Oxford University Pres.

Alexander, B. k. (2010). Demon Drug Myths. Retrieved from Bruce K Alexander: http://www.brucekalexander.com/articles-speeches/demon-drug-myths/164-myth-drug-induced

Anderson, K. (2012). Moderate Drinking, Harm Reduction, and Abstinence Outcomes. HAMS.

Buchanan, J. & Young, L., 2000. Examining the Relationship Between Material Conditions, Long Term Problematic Drug Use and Social Exclusion: A New Strategy for Social Inclusion. In J. Bradshaw & R. Sainsbury, eds. Experiencing Poverty. London: Ashgate Press, pp. 120–143.

Calabria, B., Degenhardt, L., Briegleb, C., Vos, T., Hall, W., Lyskey, M., . . . McLaren, J. (2010). Systematic Review of prospective studies investigating “remission” from amphetamine, cannabis, cocaine or opioid dependence. Addictive Behaviours, 741–749.

Compton, W., Thomas, Y., Conway, K., & Colliver, J. (2005). Developments in the Epidemiology of Drug Use and Drug Use Disorders. American Journal of Psychiatry, 162:1494–1502.

Conway, K., Compton, W., Stinson, F., & Grant, B. (2006). Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 67:247–57.

Gossop, M., Marsden, J., Stewart, D., & Kidd, T. (2003). The National Treatment Outcome Research Study. Addiction, 98:291–303.

Heyman, G. (2009). Addiction: A disorder of Choice. Cambridge, MA: Harvard university Press.

Heyman, G. (2013). Quitting Drugs: Quantitative and Qualitative Feature. Annual Review of Clinical Psychology, 9:29–59.

Lopex-Quintero, C., & Perez de los Cobos, J. (2011). Probability and predictors of remission from life-time nicotine, alcohol, cannabis or cocaine dependence: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Addiction, 106(3): 657–669.

Miller, W., & Wilbourne, P. (2003). Whatever happened to controlled drinking? Alcoholism: Clinical and Experimental Research, 27:5 Poster.

NIAAA. (September 2009). NIAAA Spectrum. NIAAA.

Peele, S. (2011, August). On the Future of Addiction. Retrieved from Huffington Post: http://www.huffingtonpost.com/stanton-peele/addiction-future_b_866009.html

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