Illustration by Fernando Vicente

This week, the Great and the Good of the AIDS industry gather in Vienna for the biennial AIDS circus. With delicious irony, the conference, held right next to the barracks of the UN’s Drug Warriors, will focus in part on getting more countries to do the one thing that really works in HIV prevention — providing clean needles to drug injectors.

That means that there will be a lot of talk about the evidence base. There’s always a lot of talk at these conferences, and although I escaped Vienna just before the start of the conference (to see the inimitable Grace Jones play Lovebox), I’m as much of a windbag as anyone. While pontificating in the BMJ video (below) about the evidence base for harm reduction, I think there’s a more important point to be made to the small coterie of scientists who wash around in the larger tide of 20,000 AIDS junkies, Poz Professionals, singing orphans, dancing hookers, jostling NGO workers, bewildered journalists and UN PR-wallahs that floods these conferences.

The point, made at greater length in an essay in the Lancet (pdf), is that we can’t look at scientific evidence in isolation. [The collage at the top of this post comes from the essay. For works of both anatomical and philosophical beauty, do browse Fernando Vicente's illustrations]. Yes, there’s lots of scientific evidence that harm reduction saves lives. But there’s a huge body of political evidence, too. And that evidence suggests that politicians do what voters want, or, at very best/worst, what politicians think they can get away with. For many politicians in many countries for many years, that has meant not spending voters’ money on helping people take drugs more safely.

As long as that is true, the scientific evidence will continue to be secondary. No matter how many well-spoken epidemiologists do their bit on YouTube.

Or, for that matter, how many nice people stand at the entrance to festivals such as Lovebox handing out orange wristbands that read “Nice People Take Drugs”. As I wandered in with my happy band of blue-tongued smurfs, I reflected that if ever there was a case of preaching to the converted…
But I also take issue with the statement, which has a UNICEF lobbyist ring to it. “Most people at risk for HIV are young” does NOT translate into “Most young people are at risk for HIV”. Nice people take drugs, certainly. But are we to believe that most people who take drugs are nice? Maybe yes, maybe no; since a majority of young people in the UK take drugs, it rather depends on your view of human nature.

Still, the folks at Release who run the campaign have come up with some fun ideas. I especially like the “Politicians Drug Confessions” playing cards.

You can buy them here.

An appeal would fly in the face of the data (which show that Insite reduces overdoses and many of the other frankly nasty things that happen to people who live with addiction to injectible drugs). It would fly in the face of pragmatism — up just one flight of stairs from the safe injecting room is a drug treatment centre which works to help people get off drugs when they’re ready to try. Detox is never an easy thing to achieve; our best bet is to have really strong links between services for current injectors and services that help them stop. But most of all it would fly in the face of any remaining self-respect that Canadians might have about their political system. Because although the newspapers talk of “the Harper government” doing this or that, Canada actually has no government right now, or at least none that answers to the normal description of parliamentary democracy. What right, then, does Harper have to be prosecuting court cases that waste tax dollars and lives?

Harper’s bully boy tactics may work for Insite in the end, though. HealthCanada is typically mealy-mouthed about an appeal, saying: “While the government respects the court’s decision, it is disappointed with the outcome. The government is reviewing the decision carefully. Until this review is complete, it would be inappropriate to speculate on future action on the part of the government of Canada.” But it’s very clear that a Liberal government would not keep banging its head against the wall of common sense that Insite represents. And by sending parliament packing until March, Harper may just have signed the death warrant for his own “government”. That would be good news for Insite users and other Canadians alike.

Thanks to Miriam for bringing this to my attention while I’m in distant Vietnam.

Note the rueful way the Canadian researchers lament the absence of US participation in the North American Opiate Medicate Initiative. In their excellent paper in the New England Journal of Medicine researchers from Vancouver and Montreal thank “the many U.S. scientists who contributed to the early design discussions but ultimately were unable to participate in the trial” because of what they ellipitcally call “financial and logistic barriers”.

This trial was being planned at the same time that the Traditional Values Coalition, defender of all that is Right and Good in America, were sticking the Republican Rottweilers on the National Institutes for Health for funding studies of sexual and drug-taking behaviour. No surprise, then, that US scientists had to drop out of the study. There is no reason in the world to believe that heroin prescription wouldn’t work as well in the US as it does in Canada, the UK or any other country at reducing consumption of street heroin, keeping people in treatment and cutting crime among that hard core of users that have tried and failed to get off smack by using methadone or just saying no. But in the current climate (yes, even with the Obama administration in occupation) there’s really not much point in doing studies in the States — no amount of evidence will lead to a policy change. As Virginia Berridge points out in an interesting editorial in the same issue of NEJM, drug policy is more a matter of history and culture than it is of science. America, founded on puritanism, has always been less tolerant of opiates than the Brits, who used them to fuel an unequal trade with China and some properly great literature.

One finding that surprised the Canadian researchers: while most people in the study obviously knew if they were taking methadone (orally) or heroin (injected) a small number of users were randomly assigned to inject hydromorphone instead of heroin. Neither they nor the study staff knew who was getting the real thing and who was getting the semi-sythetic cough suppressant. Amazingly, not one of the people shooting up cough medicine for a year could tell they weren’t taking smack. As the researchers pointed out in slightly mealy-mouthed research-speak, “the benefits of injectable opiod maintenance might be achievable without the emotional and regulatory barriers often presented by heroin maintenance”. Meaning that we might get away with prescribing drugs to help chronic users stabilise their lives if we could just stay out of the headlines. The “SMACKING UP YOUR TAXES TO SUPPORT JUNKIES!” type headlines.

A finding that didn’t surprise the Canadian researchers: people who were injecting drugs, even on prescription, were much more likely to OD than people on methadone — mostly because the heroin doesn’t mix so well with some of the other drugs they had been taking (crack cocaine use didn’t change for any of the study groups in Canada, although it fell in all groups in the UK). BUT, as the researchers point out, all but one of the overdoses happened in the study clinic, where staff were able to administer nalaxone and provide other support so that users got through the overdose ok. If they’d been out shooting up street smack, the chances are they wouldn’t have been so lucky. Which is one more reason to support supervised injecting facilities such as Vancouver’s impressive Insite.

One thing the Canadian researchers didn’t report was the relative cost of the different approaches. The UK study reported that heroin maintenance cost about £15,000 per person per year, about a third of the cost of a year in jail. But it took a report on the BBC to tell us that we could put three people on methadone for a year for the same amount. The question is: how many of them would still be on treatment at the end of the year?

(The Beeb story has an interesting video interview of one of the users of the programme, but sadly no embed code).

The governors of the United Nations Organisation on Drugs and Crime (not Drugs and Pleasure, you note, or Drugs and Health, but Drugs and Crime) gather in Vienna from tomorrow to take stock of the dismal failure of the world’s attempts to erradicate addiction by spraying crops, locking up dealers, in some countries even shooting junkies (Thailand, step forward and take a bow). Former Colombian President Cesar Gaviria, who also chairs the Latin American Commission on Drugs and Democracy, was yesterday quoted by The Guardian as saying “Prohibitionist policies based on eradication, interdiction and criminalisation have not yielded the expected results. We are today farther than ever from the goal of eradicating drugs.” The Economist goes further, calling the century-old war on drugs (launched at a conference in Shanghai in 1908) “illiberal, murderous and pointless”.

The Economist argues for legalisation. While their logic is impeccable, the likelihood that the honchos in Vienna will include legalisation as part of their roadmap for the next 10 years — or even a distant destination to put into the SatNav — is currently between nil and zero percent. It is not, however, impossible, that the balance might swing to an approach more tightly focused on cutting out the preventible harm associated with drug taking and addiction. (The two, I need hardly remind readers of this blog, are not the same, though it is hard to discern that from the approach of either the US or the UK government.) We think of “harm reduction” as needle programmes to reduce HIV and hepatitis transmission, but it is far more than that. A less prohibitionist approach might reduce the number of Mexicans killed every year while dilligently trying to keep up supplies to ever-voracious consumers in the US — around 6,000 a year. It might reduce the number of young black men who are put in touch with real criminals by being thrown into jail on drug-related offences — one in five black guys in the States spend time in the slammer, seven times the rate of white men in the same age groups. And it might shift some of the billions we spend supporting failed prohibition policies to demand reduction and quality treatment programmes. Demand reduction programmes may help young people stay off drugs in the first place, much as anti-smoking campaigns have made tobacco fundamentally uncool among young people in some populations. And we know that treatment helps people who are addicted and don’t want to be taking drugs to get clean.

In his inaugural speech, President Obama promised to “restore science to its rightful place”. Yesterday, he signed an initiative to take the church-led meddling of the Bush era out of science. “It is about ensuring that scientific data is never distorted or concealed to serve a political agenda — and that we make scientific decisions based on facts, not ideology,” Obama said.

The fact is that the 100 year long war on drugs — a war motivated by ideology not science — has failed. It has made life more dangerous and uncertain for people in the poor countries that produce most drugs, and the rich countries that consume them. Even the head of UNODC is begining to nod towards harm reduction. Perhaps, with Obama’s words ringing loudly in their ears, those gathered in Vienna this week will opt to try a new stratgey.

Switch is a coalition of community groups based in the Western city of Bristol. The Guardian reports that the group was finding that a lot of dealers wanted out, but felt trapped because there was little else they could do that would maintain their often quite expensive lifetsyles. The publicly-funded group works largely with dealers at the bottom of the food chain, those who churn small deals for the bigger fish, as a way of funding their own drug habits. The story is a bit vague about what Switch actually offers, beyond “suggesting ways of giving [the dealer] the support and skills they need to break away from the streets.”

I’m in two minds about initiatives like this. On the one had, if people really do want out, then any help we can give them is surely a good thing (and certainly cheaper for taxpayers than many more years of cycling them in and out of jail). On the other hand, it smacks rather of those rescue missions for sex workers, which so often do more for the moral superiority of the rescuer than they do for the future of the working girl. Of course it does also open up the possibility of working with those dealers who don’t want to give up their jobs to help make drug-taking less dangerous to their clients.

For the small-time dealer, the “golden cage” probably seems a long way off in any case. While prices of petrol, heating and food soar, prices of drugs are still coming down, according to an annual survey of drug trends in the UK published today by Drugscope. The exception is heroin. The price of smack on the street has risen by 14% in the last year (to £49 a gramme, close to U$ 90), and things are bound to get worse. Just over the summer, the wholesale price has shot up by 30%, to £17,000 a kilo. (That means that dealers within the UK are current creaming off £32,000 a kilo, but I wonder how much of that filters down to the (mostly) boys that Switch are dealing with.) Even the relatively modest price rise on the streets is already affecting consumption patterns, according to Drugscope, with some heroin users switching to Valim (diazepam), which is just £1 a pill. They take it when they can’t afford the real thing, when they’re out of methadone, when they’re coming down. That’s a worry, because it increases the risk of overdose.

Whatever we do on the streets, we could certainly be doing more for drug users (and perhaps pushers) when they are in jail. I was interested to note yesterday (again in The Guardian that the drugs charity RAPT has joined a consortium bidding to run two jails in the UK. They’re hooked up not just with the security firm G4S, but with prison reform charity Nacro. Strange bedfellows, but it should allow drug treatment and post-release programmes to be more thoroughly integrated into the prison system, and that can only be a good thing. On the downside, RAPT is very much focused on abstinence-based solutions to drug abuse; that doesn’t bode well for encouraging the prison system to make sterile injecting equipment available to people who are going to go on shooting up in jail, no matter who runs the service.

In most of the world, we’ve got precious little idea how many people get infected with HIV each year. Generally, we report HIV prevalence — the number of people who have HIV right now. Some of those people will have been infected last month, some will have been infected 10 years ago. It doesn’t tell us much about what’s happening right now. What we really want is information on HIV incidence — the number of people who got infected in the last year. Recently the US has been trying out new technologies that can distinguish between an old and a new infection. That tells us what proportion of the people tested this year were infected this year; then we have to add in a guesstimate for how many people were infected this year but didn’t get tested. CDC last month published national estimates of incidence for 2006. Now New York City has published its own estimates.

And yes, New York is ahead of the curve. Whites in the city are four times more likely to be newly infected with HIV than they are nationally, Hispanics three times more likely and blacks twice as likely. Overall, half of all new infections are among men who have sex with one another. In fact among white New Yorkers, nine out of 10 new infections are among men, most of them gay. Seven out of 10 of the blacks who got HIV in New York in 2006 were men, and over half of them picked up HIV in anal sex with another man. So much for the “feminising epidemic”.

Blacks of the “post-AIDS generation” — men under 30 who probably became sexually active after effective HIV drugs became the norm in 1996 — seemed particularly hard hit. Some 46% of black men who got infected in sex with another man were under 30, compared with just 24% of whites.

New York doesn’t have any systematic estimates of the number of people in each high risk category, which makes it hard to compare rates across risky behaviours (in this respect, it is definitely not ahead of the curve, falling way behind countries such as China, Indonesia and Nepal, all of which estimate how many drug injectors, sex workers, clients and high risk gay men there are in each district nationwide). But it does look as though a “good news” story might be the comparatively small numbers of new infections among drug injectors in New York City. Just 8% of all new infections were among injectors, a flagrant success for the city’s harm reduction policies.

In the No Shit Sherlock department, I just have to draw attention to this trenchant analysis from dbTechno: “The biggest issue with prevention methods thus far has to do with people who are infected with the AIDS virus infecting those who do not have HIV/AIDS.”

That may be changing. One thing UNODC is really good at is tracking drug production, supply and street prices, so I always keep my eye out for its fascinating annual report. The World Drug Report 2008 does not disappoint. Opium production in Afghanistan almost doubled in 2007. And in Colombia, where the US has funded a massive attack on coca production, output is up by 27 percent. Ho hum. But for me, the really fascinating thing was the spin that the head of UNODC, Antonio Maria Costa, put on the report. This from the press release that accompanied the report:

Pointing out that resources for public security far outweigh those devoted to public health, Mr. Costa called for a stronger focus on health – the first principle of drug control. “Drug dependence is an illness that should be prevented and treated like any other,” he said.

This may sound like common sense, and it is. But it comes from a man who has in the past instructed his staff to remove from agency reports all mention of “harm reduction” (aka “public health”) approaches to addiction and drug use. It’s a tribute to a small number of people who have been working inside UNODC to try to put drug users’ health more firmly on the agenda. Chapeaux to Christian Kroll, Karl Dehne, Gray Sattler and others.

Opposition to harm reduction comes in large part from the US government. But not, it seems, from thoughtful citizens. I note that a grand jury in California has recommended that local government fund a needle exchange programme as a way of reducing HIV and Hep C. With enough of these small steps, we may walk towards the goal of keeping drug users alive until they get clean.

“In my opinion, supervised injection is not medicine; it does not heal the person addicted to drugs,” Health Minister Tony Clement told the House of Commons health committee Thursday, according to The Globe and Mail

Well duh! The most ardent supporters of harm reduction would not claim that supervised injection heals addicts. They claim, rather, that it increases the likelihood that people will a) stay alive long enough to get off drugs and b) not be infected with a fatal disease once they do get clean. Unlike Mr. Clement and his cronies, they back up their claims with plenty of evidence.

That evidence is giving public health officials (as opposed to politicians) a headache. According to the Globe and Mail:

David Butler-Jones, Canada’s chief public health officer, looked decidedly uncomfortable when asked whether he agreed with Mr. Clement.
“The science, I think, speaks for itself. The debate speaks for itself,” Dr. Butler-Jones replied. “We provide the best advice we can. Governments and jurisdictions, as appropriate, make their decisions and have the political context in which they make their decisions.”

(Apologies to Goddard for ripping off his great cartoon. I did try to pay for it on line, but the site led me on such a merry dance that I gave up…)

Then: bang! A sensible Canadian judge has ruled that the Insite injecting room should stay open for another year, with or without permission from the nation’s Prime Minister and his conservative flunkies. Dean Wilson, one of the heroin users who brought the case against the government, did some gloating of his own: “A couple of junkies knocked off the PM,” he told the Vancouver Sun.

I’ve said before that the evidence stacks up in favour of Insite. Opponents appear to think otherwise but are unable to cite any sensible data to support their arguments. Some forgo arguments and just rant incoherently. But most of the comment in the blogosphere is far more sensible. A large number of Canadians apparently support a pragmatic approach to addiction.

The British Columbia Supreme Court judge Ian Pitfield certainly sounded sensible. In his ruling, Mr Pitfield said that the State did not have a right to deny life-saving services to drug addicts. After all, he pointed out, the same state quite happily provided treatment for alcoholism and the consequences of smoking. And, one might add, for obesity, sports injuries, and all sorts of other conditions that result from people doing not very smart things for fun, for money or out of sheer idleness. Conditions that result from us being human, in other words.

Let’s hope Mr. Wilson’s victory is allowed to stand. (see following post…)

“Scientists accuse Tories of ‘despicable’ interference”, yells a headline in the Globe and Mail. “An article published in the International Journal of Drug Policy charges that the Conservative government interfered in the work of independent scientific bodies, attempted to muzzle scientists and deliberately misrepresented research findings because it is ideologically opposed to harm-reduction programs,” reports Andre Picard. (I’d love to provide you with a link to the original article; the IJDP is the official journal of the International Harm Reduction Association, but they’ve decided to limit their policy impact by publishing through a restricted access Elsevier journal.)

At issue, on the face of it, is funding for research and a continuation of an exemption from national law that allows the safe injecting site to operate as a research site. But the real issue is, as always, whether the conservative government wants science or political expediency to inform its drugs policy.

Last month, an independent committee published a very detailed report about the impact of the Insite safe injecting space, which serves around 600 people a day, has helped over 300 people stay alive after an overdose, and overseen 220,000 safe injections. Fans of the programme cherry-pick the positive findings: more hard-core users getting into treatment, fewer people shooting up in public, less needle sharing, while opponents of harm reduction highlight the downsides. They revolve mostly around our inability to prove the effect of the programme, the usual chestnut of public health prevention. They complain too about the limited impact of the programme — it reaches only five percent of injectors in Vancouver’s downtown east side. But that’s in part the tyranny of a “pilot” set-up. It seems to me that should be a reason to expand the programme, not to pull it.

We’re nowhere near the last word on this, but for today let it go to the eminently sensible Provincial Health Officer for British Columbia, “I’m a realist enough to know that public policy is not based solely on science, but you would hope that policy would be strongly swayed by science, particularly in health care,” he told the Globe and Mail. “”If there was a validated intervention for hernia repair would we accept that the government step in and say: ‘We don’t like hernia repair’? I don’t think so.”