One hundred years ago, German chemists introduced heroin to the world. On Saturday the New York Academy of Medicine held a conference celebrating the drug's latest use, "heroin maintenance": medically supervised distribution of pure heroin to addicts. The academy's First International Conference on Heroin Maintenance introduces to our shores the latest example of the pernicious drug-treatment philosophy known as "harm reduction."
Harm reduction holds that drug abuse is inevitable, so society should try to minimize the damage done to addicts by drugs (disease, overdose) and to society by addicts (crime, health care costs). According to the Oakland, Calif.-based Harm Reduction Coalition, harm reduction "meets users where they are at . . . accepting for better or worse, that drug use is part of our world."
Its advocates present harm reduction as a rational compromise between the alleged futility of the drug war and the extremism of outright legalization. But since harm reduction makes no demands on addicts, it consigns them to their addiction, aiming only to allow them to destroy themselves in relative "safety"--and at taxpayer expense.
Specious Choice
The recent debate over needle exchange illuminates the political strategy of harm reductionists. First, present the public with a specious choice: Should a drug addict shoot up with a clean needle or a dirty one? (Unquestioned is the assumption that he should shoot up at all.) Then misrepresent the science as Health and Human Services Secretary Donna Shalala did when she pronounced "airtight" the evidence that needle exchange reduces the rate of HIV transmission. In fact, most needle exchange studies have been full of design errors; the more rigorous ones have actually shown an increase in HIV infection.
And so it is with heroin maintenance. First, the false dichotomies: pure vs. contaminated heroin; addicts who commit crime to support their habit vs. addicts who don't. Then the distortion of evidence. The Lindesmith Center, one of the conference sponsors, claims that "a landmark Swiss study has successfully maintained heroin addicts on injectable heroin for almost two years, with dramatic reductions in illicit drug use and criminal activity as well as greatly improved health and social adjustment."
In fact, the Swiss "experiment," conducted by the Federal Office of Public Health from 1994 to 1996, was not very scientific. Addicts in the 18-month study were expected to inject themselves with heroin under sterile conditions at the clinic three times a day. They also received extensive counseling, psychiatric services and social assistance (welfare, subsidized jobs, public housing and medical care). Results: The proportion of individuals claiming they supported themselves with illegal income dropped to 10% from 70%; homelessness fell to 1% from 12%. Permanent employment rose to 32% from 14%, but welfare dependency also rose to 27% from 18%. The rate of reported cocaine use among the heroin addicts dropped to 52% from 82%.
These numbers may look promising, but it's hard to know what they mean. Verification of self-reported improvement was spotty at best. And addicts received so many social services--five times more money was spent on them than is the norm in standard treatment--that heroin maintenance itself may have played no role in any overall improvement.
Definitions of success were loose as well. Anyone who kept attending the program, even intermittently, was considered "retained." By this standard, more than two-thirds made it through--a much higher retention rate than in conventional treatment. But considering that the program gave addicts pharmaceutical-grade heroin at little or no cost, it's astonishing that the numbers weren't higher. It turned out that the patients who dropped out were those with the most serious addiction-related problems--those who had been addicted the longest, were the heaviest cocaine users, or had HIV--the very groups that are of the greatest public-health concern.
What's more, the researchers did not compare heroin maintenance with conventional treatments such as methadone or residential, abstinence-oriented care. They abandoned their original plan to assign patients randomly to heroin maintenance or conventional methadone--because, among other reasons, the subjects, not surprisingly, strongly preferred heroin.
"The risk of heroin maintenance is the incentive it provides to 'fail' in other forms of treatment in order to become a publicly supported addict," says Mark Kleiman of UCLA School of Public Policy. And in fact, once the heroin maintenance project started, conventional treatment facilities reported a sharp decline in applications, even though the rate of drug use remained steady.
The Swiss heroin experiment was born out of desperation. In the mid-1980s, the Swiss government became disenchanted with drug treatment and turned to a policy of sanctioned drug use in designated open areas. But this was unsuccessful; the most visible failures being the squalid deterioration of Zurich's Platzspitz Park (the notorious "Needle Park") and the syringe-littered Letten railway station.
It is telling that harm reduction efforts have evolved in countries that provide addicts with a wide array of government benefits. Rather than throw up their hands at the poor record of drug rehabilitation, the Swiss and others should acknowledge the extent to which welfare services enable addiction by shielding addicts from the consequences of their actions, financing their drug purchases and encouraging dependency on public largesse.
Nonetheless, Switzerland has ardently embraced heroin maintenance. The Federal Office of Public Health plans to triple enrollment next year to about 3,000; and in 2004 the Swiss Parliament plans to decriminalize consumption, possession and sale of narcotics for personal use.
Not everyone shares Bern's enthusiasm. Wayne Hall of Australia's University of New South Wales was an independent evaluator for the World Health Organization who assessed the experimental plan of the Swiss project. "The unique political context . . . of the trials . . . meant that opportunities were lost for a more rigorous evaluation," he wrote. In February, the International Narcotics Control Board of the United Nations--a quasijudicial body that monitors international drug treaties--expressed concern that "before [completion of] the evaluation by the World Health Organization of the Swiss heroin experiment, pressure groups and some politicians are already promoting the expansion of such programmes in Switzerland and their proliferation in other countries."
And indeed, the trials' principal investigator and project directors have traveled to Australia, Austria, Germany, the Netherlands and elsewhere promoting heroin maintenance. They won a sympathetic hearing in the Netherlands, which plans to begin a heroin experiment next month. This isn't surprising; after all, this is a country that has a union for addicts, the Federation of Dutch Junkie Leagues, which lobbies the government for services. In Rotterdam last month, I visited a Dutch Reformed church where the pastor had invited two dealers in to sell discounted heroin and cocaine. He also provided basement rooms where users could inject or smoke heroin.
Nothing in Return
Even if heroin maintenance "worked"--if it could be proved that heroin giveaways enhanced the addicts' health and productivity--we would still have to confront the raw truth about harm reduction. It is the public-policy manifestation of the addict's dearest wish: to use free drugs without consequence. Imagine extending this model--the use of state-subsidized drugs, the offer of endless social services and the expectation of nothing in return--to America's hard-core addicts.
Today the U.N. General Assembly opens a special session on global drug-control policy. Harm reduction advocates will tell the world body that drug abuse is a human right and that the only compassionate response is to make it safer to be an addict. The Swiss and the Dutch seem to view addicts as irascible children who should be indulged, or as terminally ill patients to be palliated, hidden away and written off. But heroin maintenance is wrong. As an experiment, thus far it is scientifically groundless. As public-health policy it will always be a posture of surrender.
Dr. Satel is a psychiatrist and lecturer at the Yale University School of Medicine.
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