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Hooked on Dogma; U.S. Drug Warriors Ignore Switzerland's Success With
Washington Post Sunday 21 Dec 1997 refuge for drug users, a place where they would be tolerated by police and even offered sterile needles and medical care. The goal wasn't to condone drug use, but to control its side effects -- mainly the diseases contracted by users and spread to the population at large. But, by the early 1990s, "Needle Park" bulged with Europe's outcasts. As crime rose in the area and a once-charming garden became an eyesore, Zurich ended the experiment. The shapers of American drug policy -- from former czar Bill Bennett to Drug Enforcement Agency chief Thomas Constantine -- often cite Needle Park as an argument against changing America's hard-line drug policies. But the Swiss, aware that dispersing the Needle Park junkies did not eliminate the serious harm they were doing to themselves and to society, have continued to pursue novel approaches toward solving their country's drug problem. For the heroin addicts who would not respond to conventional treatment, the government decided to take the radical step of offering heroin itself. From 1994 to 1997, in 18 treatment centers around Switzerland, 1,146 male and female addicts received injections of pure heroin three times a day. Led by Ambros Uchtenhagen, an internationally renowned social scientist, the Addiction Research Institute in Zurich kept careful tabs over the experiment. The goal was not to offer the drug, in perpetuity, to all comers. Rather, the researchers hoped to mitigate the injurious behavior of a small group of addicts for whom repeated treatment regimens had failed. The success was striking. Heroin maintenance, Uchtenhagen and his researchers found, not only improved the lives of addicts but benefited society in tangible ways. Before going on heroin maintenance, 59 percent of the Swiss addicts in the program were involved in criminal activity. Because they no longer needed cash to pay exorbitant prices on the black market, by the end of the experiment that number dropped to 10 percent. For the same reason -- and also because participants in the program were required to undergo counseling -- many addicts climbed out of the underworld, found housing and began to work in mainstream jobs. The rate of homelessness in the group dropped from 12 percent to near zero. The health benefits were also unambiguous: HIV and hepatitis infections dropped sharply, and the annual death rate fell by half. Day to day, many fewer addicts contracted skin infections and other diseases. A small but significant portion of the group even left the program for abstinence treatment. If the Swiss experiment had failed, you can be sure that American officials would trumpet the news, just as they so regularly refer to Needle Park. But the actual results are less convenient for advocates of the status quo. And so the response has been to ignore it. For example, in the past four months, the National Institute on Drug Abuse (NIDA), which controls a $ 520 million budget and 85 percent of all research on the health effects of drug abuse and addiction, has organized two major conferences on heroin without considering the Swiss research. The lesson is not that heroin maintainence ought to be embraced here. The episode illustrates, however, how discussion of America's drug policy has been constricted by the dogma of the drug war. While vigorous research and debate is taken for granted in public policy debates about, say, welfare policy or affirmative action, such discussion is largely absent from the study of drugs. To ignore innovative ideas and approaches -- especially complicated, unsettling ones -- is at best unsound. At worst, it will lead to outright failure. While it is a legitimate social policy goal to eliminate heroin use entirely, the American approach of zero-tolerance has proven remarkably ineffective. About 600,000 Americans are addicted to the drug. That number has increased over the past several decades, despite billions of dollars and hundreds of thousands of arrests. Meanwhile, these addicts are causing a great deal of harm -- to themselves and to the rest of us. Intravenous drug users are now the single biggest factor in the spread of HIV. Eighty-five percent of addicts commit some kind of crime, ranging from petty burglary to homicide. The financial costs of untreated heroin addiction is an estimated $ 20 billion a year, according to a National Institutes of Health (NIH) panel. And yet, for the same reasons that they wouldn't contemplate heroin maintenance, American officials have kept tight restrictions on the medical treatment with the best track record: methadone maintenance. Only 20 percent of heroin addicts have access to methadone, a synthetic opiate that often removes the craving for heroin. In November, a panel of scientists convened by NIH and NIDA urged expanded use of methadone maintenance. This treatment regimen, the panel concluded, "is effective in reducing illicit opiate drug use, in crime reduction, in enhancing social productivity, and in reducing the spread of viral diseases such as AIDS and hepatitis." The problem, the panel reported, is a public that refuses to consider heroin addiction in a medical context. Drug therapy for addiction is viewed with suspicion because it's seen as just another addiction. "It's not the zero tolerance option and so it's unpopular," says David C. Lewis, a professor of medicine and community health at Brown University. The irony is that Americans embrace pharmaceutical treatments for every conceivable human ailment, from impotence to depression to hyperactivity to stage fright. But drug addicts are regarded as castoffs. Even discussing heroin maintenance is strictly taboo -- as was evident at the same NIH conference that concluded by lamenting the stigma attached to methadone treatment. Before the conference, NIDA assembled a bibliography that was supposed to contain every known study of the medical treatment of heroin addiction. The Swiss study was not among them. When Lewis made brief mention of the study, he was criticized by his colleagues for doing so. "Scientists and clinicians -- people I regard as leaders and look to with respect -- are concerned that just bringing it up will cause difficulty," Lewis said. "You can't talk about these things in this country without causing controversy, which is a great sadness." NIDA is a perfect example of the paralysis that permeates the discussion about American drug policy. In 1992, the institute was put under the aegis of NIH specifically to insulate it from the prejudices of public opinion -- to evaluate and commission drug-related research based on science, not politics. Nevertheless, NIDA gives priority to studies that are likely to support government positions and regularly interpret science with obvious political intent. That makes debate around scientific questions concerning drug issues difficult. "If you were at NIDA," says Peter Reuter, the director of the University of Maryland's Drug Policy Research Center, "you would say, 'How can I seriously argue that [discussing heroin maintenance] would make a difference to programs here?' " Worse than not making a difference, it could do a great deal of harm, if outraged congressmen moved to slash the institute's research budget. So public opinion keeps researchers from considering new ideas. But the public can't reconsider its biases without being presented with new ideas. The cycle is difficult to break, but not impossible. Consider the case of medical marijuana. For years, NIDA has stonewalled researchers trying to conduct large-scale trials of the plant's utility in treating diseases such as glaucoma and chemotherapy-related nausea. Then, California passed an initiative legalizing marijuana for medical use and the Clinton administration finally instructed NIDA to conduct studies. "It's a case where popular politics has really driven science," says Reuter. By contrast, Swiss scientists who, like their American counterparts, depend on government support, seem more free to conduct research in the addiction field, which citizens can then judge on the merits. Indeed, after the results of the heroin maintenance experiment were published this summer, Swiss voters were asked in a referendum whether the program should continue. More than 70 percent said "yes." What Swiss voters seem to have realized is that there is a middle ground between condoning heroin use and insisting all addicts kick their habits immediately. As with nicotine, a drug with a similar addiction profile, heroin use is not a simple matter of exercising free will. Dependence is fierce and all-consuming; withdrawal wreaks havoc on both the body and mind. The pleasure of heroin, writes David Lenson in his book, "On Drugs," takes over the body, "so that in withdrawal, ordinary consciousness is received as pain." Anja Dobler-Micola, a member of the Swiss research team, says, "We always get this question: 'Shouldn't therapy be drug-free?' But is drug freedom the first step, or is it the last step?" Addicts in the program, she says, "realize how dependent they really are." Freed from the consuming street life and required to undergo counseling, they are able to reflect and make more rational choices about their future. Now, if only Americans could start making rational choices about their drug policy.
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