1084th General Monthly Meeting
Can we Win the War on Drugs?
Dr James Bell, Director of The Langton Centre andDr Don Weatherburn, Director of the Bureau of Crime Statistics and Research
Date: Wednesday 1st September, 1999
Time: 6 for 6:30pm
Venue: Hallstrom Theatre, Australian Museum (enter from William St.)
ABSTRACTS
Drug Law Enforcement, Heroin and Harm Minimisation
Dr Don WeatherburnDirector of the Bureau of Crime Statistics and Research
Australia's Governments have agreed on a harm minisation approach to the management of illicit drug use. There are, however, two classes of harm associated with any form of drug use. The first class (direct harm) derives from the effects of a drug on the user or those directly affected by the users behaviour. The second class (induced harm) derives from our efforts to control or manage the consumption of illicit drugs. Strategies which are effective in minimising direct harm associated with a drug often increase the induced harm associated with it. This paper analyzes the problem and makes some suggestions as to how policy should address it.
Naltrexone - Faith, Hope, but Little Clarity
James Bell,The Langton Centre
Heroin addiction is a chronic, relapsing and remitting predicament. The "natural history" of heroin addiction is that each year 2-5% of addicts discontinue drug use permanently, and 1-2% die, mostly of overdose. At this time there is no evidence that treatment improves on the rate of spontaneous remission of dependence and achievement of abstinence from drugs.
Traditionally, and in the popular imagination, "treatment" involves profound changes in attitude and values - the process of recovery being a spiritual and moral one. In the last 15 years, Australia has been one of the nations leading the world in adopting the "harm minimization" philosophy, in which the goal of recovery is not the only or primary aim of intervention. Education, needle and syringe programs and methadone maintenance have been the major strategies, based on evidence that these approaches can improve survival, improve quality of life, reduce criminal activity, and reduce the spread of parenterally transmitted viruses, among injecting drug users.
Naltrexone seized the popular imagination in Australia after it was promoted in the media as a cure for heroin addiction. The hope for naltrexone far exceeded evidence of its effectiveness, but in response to public demand governments supported several trials of the drug. NSW Health funded a pilot study of naltrexone treatment at The Langton Centre. The objectives were (1) to determine whether naltrexone-accelerated detoxification with minimal sedation is an acceptable and effective form of induction onto naltrexone; and (2) to monitor outcomes of detoxified patients treated for 3 months with naltrexone. 30 patients (15 heroin users and 15 patients seeking withdrawal from methadone) were treated. Adequate follow-up information was obtained on 29 patients. The outcome measures were induction onto naltrexone, retention in treatment over 3 months, relapse to heroin use.
70% of subjects reported that rapid detoxification with minimal sedation was quite acceptable. 60% of subjects required only 1 night in hospital. 24 patients (80%) were successfully inducted onto naltrexone. At 3 months, 6 subjects (20%) were still taking naltrexone, 11 had gone onto methadone maintenance, 5 were abstinent not taking naltrexone, 7 had relapsed to heroin use, and 1 subject died of a heroin overdose. Four subjects still taking naltrexone reported occasional heroin use. Thus, while induction onto naltrexone was comparable to published data, as in other studies of naltrexone in opioid dependence, retention was low, and relapse to heroin use was common.
Centenary of Heroin (the word, that is)
Report on the General Monthly Meetingby Edmund Potter, 6th September 1999.
The 1084th General monthly Meeting took place on Wednesday, 1st September 1999, at the Halstrom Theatre, Australian Museum Sydney, in the presence of the Society's President (Assoc. Prof. Tony Baker) and a number of invited guests. Two speakers, Dr James Bell (Director, Langton Centre) and Dr Don Weatherburn (Director, Bureau of Crime Statistics and Research) addressed two related aspects of the contemporary addictive-drugs scene.
Dr Weatherburn spoke first, choosing his theme "Drug law Enforcement, Heroin and Harm Minimisation", supporting his inferences with data from a recent survey of several hundred drug-users. Precise statistics can be elusive, but NSW has around 40 000 recent drug-users, each spending a median of $150 per day on the habit at $30-50 a cap. The drug would be far cheaper but for a risk loading attached to delivering the illegal substance to the user from its Asiatic sources. There are twice as many male users as there are female, and of all users some 70% have been arrested and half have been imprisoned as a result.
Even so, in the speaker's words, "heroin is as easy to get as a suburban train". Users commonly fund their habit from the proceeds of burglary, shoplifting, prostitution, and supplying other addicts. About 45% of heroin users are unwilling to switch to the familiar alternative, methadone, arguing they are still drug dependent and dislike the side effects. In the users' parlance, visiting the methadone clinic is encoded as "liquid handcuffs". Nevertheless, using methadone lowers dependency costs to an average of $450 per day per user, representing a significant drop in crime rate.
The harm due to heroin can de divided into direct harm to the user and induced harm for the rest of us. Direct harm includes diminution of birth weight, child neglect, road accidents, and consequences of unhygienic use and erratic purity. Induced harm arises from organised and property crime, homicide, suicide, and police corruption. The speaker was critical of police who destroy equipment when they catch an injecter, since the equipment is supplied to reduce the spread of AIDS.
Dr Bell's address was entitled "Naltrexone - faith, hope, but little clarity", and he supported this theme with the results of his recent funded trial of Naltrexone on volunteers addicted to heroin or to methadone. Dr Bell remarked that, although a proportion of his volunteers had the resources to support their habit, they were still keen to overcome their addiction, following press reports of near-miraculous "cures" attributed to Naltrexone.
Dr Bell explained that Naltrexone operates by blocking opiate receptors - a single 50 mg dose will render ineffective 30 mg of heroin. For the confirmed opiate user, Naltrexone precipitates a severe but abbreviated withdrawal episode lasting less than two hours, promising a quick cure and attracting the eye of a public inured to almost daily scientific "breakthroughs".
Sadly, even occasional relapse to heroin use is perilous, because Naltrexone vitiates heroin's euphoric effects, encouraging overdosing in order to seek them. This may explain why Naltrexone plus counselling appears more effective that either measure alone. In Dr Bell's trials, 60% of subjects were detained only one night in hospital, and 80% were still taking Naltexone 8 days later. However, at 3 months that percentage had fallen to 20%, and a further quarter had relapsed to heroin. One of the original 30 subjects had died from overdosing. These overall results were comparable with those of other independent trials.
Dr Bell concluded Naltrexone offers no sure cure for heroin addiction. Answering a question, he considered that urging youth never to touch heroin stood to be similarly unsuccessful, and could indeed encourage experimentation.
Both 30 minute talks each attracted 13 minutes of keen questioning, reflecting the concern of an audience left pondering the fact that each year no more than 1 in 20 of heroin addicts forsake their habit.