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).

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.

The biggest offenders in the drug market in jail appear to be the screws, the prison staff who are topping up their salaries by dealing smack to the people they are locking up. So there’s a surprise.

Listen to this fantastic radio documentary about drugs in UK jails from BBC’s Radio 4. Go ahead, listen.(Though be warned, there are things you wouldn’t want to try at home, like strapping steroids to your scrotum, and smuggling mobile phones in through the back door, as it were…)

With all those drugs floating around, prisons don’t seem a very healthy environment for impressionable young souls. And yet it seems that police, striving to meet targets for a charter-obsessed government, are funneling more and more young people into the criminal justice system, even for petty offences that would once have been dealt with informally. Into the system doesn’t necessarily mean in to jail, of course, but it’s the first step — it gives you a record that can make it more likely that you’ll get put away for a relatively minor offence later. Not a good idea, according to Dr Andrew McLellan, Chief Inspector of Prisons for Scotland, who complains that putting more people on short-term sentences in overcrowded jails actually makes Scotland a more dangerous place.
One bit of good news in a miserable picture: young users in the UK are less likely to be using smack or crack than their elders, by which I mean those who have hit the ripe age of 25. Of course that does mean they’re more likely than old farts of 27 to be using coke, speed and E, according to a new study fromLiverpool John Moore University.

Thanks to the always informative UK Drug Policy Centre for these tips.

(An aside: say what you like about random testing, at least it gives you fairly accurate figures. Antonio Maria Costa, who heads the UN drug police UNODC, thinks he can tell who’s on drugs just by looking. Speaking at a conference yesterday, he described a meeting organised by the Drug Policy Alliance as follows:

“1200 participants, 1000 lunatics, 200 good people to talk to. The other ones obviously on drugs.”

Thanks to Transform for that report.) Now back to the UK.

The drug the government is getting uptight about is buprenorphine, an opiate substitute which is widely used in drug treatment outside jail (and sometimes inside it, too). Unauthorised use of bup (aka Subutex) in jails stands at 1.9% nationally, but more than one inmate in 10 is taking it in several jails, and in some its one in five. Justice Minister David Hanson has decided to deal with this problem by forcing all jails to introduce random testing for buprenorphine (currently only around two thirds of jails do). His theory is that random testing will act as a deterrent, pointing out that use of other drugs has fallen from 24% to 9% since random testing was introduced in 1997.

Perhaps better treatment would help more. To give the government its due, the number of prisoners on substitution therapy has more than tripled in the last 10 years, but there’s still a long way to go. The prison policy update dedicates most of its drugs section to supply reduction, making no commitments for increased treatment. There’s not a whisper about allowing clean needles for injectors in prisons, of course, even though the UK taxpayer continues to fund life-saving needle exchange programmes in jails in other countries. Go figure.

While I’m on drugs, a rare bit of praise for UNAIDS. Having allowed harm reduction to teeter on the brink of invisibility, they seem to be finding their voice again. Could it be that they smell change in Washington?

On the other hand, the plan commits the government to treatment and prevention which follows evidence, not ideology. This includes “injectable heroin and methadone where they have been proved to work and reduce crime”. This will enrage people who believe that taxpayers shouldn’t be buying smack for addicts, even if it keeps the thieves from their doors.

Interestingly, amphetamines have fallen out of favour with Brits since 1996, but cocaine use (including crack) has been on the rise. Not surprising: a gram of coke costs almost exactly the same now as it did 20 years ago in absolute terms, while wages and indeed benefits have risen sharply. (More about supply, demand and pricing of drugs in this Home Office report.)

The strategy argues for better methadone maintenance programmes in UK prisons, to which I say hear, hear. Predictably, since this comes from the Home Office, there’s nothing on rolling our needle exchange programmes in jail (though it seems Scotland may take the initiative on that soon). I guess you can’t have it all. One of the things I do like about the strategy is that it doesn’t have a pigs-might-fly “Drug Free Britain” goal. Rather, it focuses very clearly on problem drug use. This, for example, from the Home Secretary’s foreword:

“Our ambition is clear. We want a society free of the problems caused by drugs”

I can think of a couple of other nations that would do well to adopt such pragmatism.

Tut tut, said George Bush. And in his budget proposal for 2009, he will try to have the ban reinstated. He did this on the very day that the NAACP and others called on Congress to drop a ban on federal funding for needle programmes nationwide (a position which is, incidentally, supported by Barack Obama. NAACP is no doubt shocked at HIV prevalence among the capital’s blacks, which, at close to 5%, rivals that of many African nations. The organisation has been banging the “more clean needles, please” drum since at least 1997, to no avail. While it makes not a jot of sense, the administration’s “clean needles spread drug use” drum appears to sound more loudly.

The not-so-good (but oh-so-predictable) news: the Bush administration thinks these programmes are a bad idea. According to deputy-drug czar Bertha Madras, knowing someone might save your life if you overdose encourages people to shoot up drugs. On top of that, Madras suggests it’s a bad idea to let junkies, rather than doctors, take care of overdose victims, because “drug users aren’t likely to be competent to deal with an overdose emergency”.

When I moved back to Jakarta in 2001, I lived on a needle park (so did the current vice president of Indonesia, while the governor of Jakarta and the US ambassador were just a block away). One night I was nearly knocked down by a gaggle of kids who were running away from something — a cop, I guessed. But no, they were running away from one of their friends, who was busy over-dosing on the pavement outside my house. So yes, they were “not competent” to deal with the overdose. But had they had an easy-to-use nasal spray handy, and ten minutes of training in what to do, they might not have panicked, and might not have left their mate to his fate. The fact is, other drug users ARE the frontline forces when other users OD; if we equipped them properly, they’d become competent.

I got that kid to hospital, but he was lucky. Over eight in 10 injectors in Indonesia say that one of their immediate injecting circle has died of an overdose. Madras thinks this isn’t enough, apparently. In comments that have sparked outrage across the blogosphere (see for example here (beautifully illutrated) and here and here), she also suggested that overdosing provides users with a reality check that will encourage them to give up drugs. I’m just waiting for a public health official to argue against seat-belts, because going through the windscreen can provide a reality check that will encourage people to give up driving fast.