Maintenance
Therapies
Drug
substitution and maintenance approaches have a long history.
These involve providing drug addicts with legal access to drugs
that would otherwise be obtained through illegal means. The
basic rationale is that of harm reduction: if some people are
unable to quit using drugs, both users and society at large
benefit if these users, i.e., addicts, are able to switch from
"black market" drugs of indeterminate quality, purity
and potency to legal drugs, of known purity and potency, obtained
from physicians, pharmacies and other legal channels. The risks
of overdoses and other medical complications decline; the motivation
and need for addicts to commit crimes to support their habits
drop; addicts are more likely to maintain contact with drug
treatment and other services, and more able and likely to stabilize
their lives and become productive citizens. In the United States,
morphine maintenance clinics proliferated during the first two
decades of this century, before being closed under pressure
by law enforcement authorities.
The
most famous U.S. clinic, the Shreveport Clinic, operated in
Louisiana from 1919 to 1923. The clinic enjoyed the support
of federal and city judges, local law enforcement and pharmacists,
all of whom, fearing an increase in crime, opposed efforts
by federal narcotics agents to close the clinic. The practice
of prescribing heroin to addicts was standard in England from
the 1920s to the 1960s. In response to political pressure
from the U.S., heroin maintenance was severely curtailed in
1971 when passage of the Misuse of Drugs Act added burdensome
regulations. Government disapproval led to a sharp decline
in the practice among private physicians. The loss of a controlled
distribution system and subsequent creation of an unregulated
illicit market allowed the number of heroin users to skyrocket
from fewer than 2,000 in 1970 to upwards of 300,000 today.
What was once discouraged is now being promoted in England,
in large part due to a perceived increase in heroin-related
crime.
Maintenance
therapies made a comeback in the U.S. during the mid-1960¡¯s
with the advent of methadone, a synthetic morphine substitute
discovered by German scientists during World War II. Methadone
maintenance is now widely regarded as the most effective known
treatment for heroin addiction. Used properly, methadone reduces
drug use and related crime, death, and disease among heroin
users. But methadone has been handicapped by restrictive government
regulations, by misinformation - among treatment providers
and drug users alike - and by prejudice against methadone
treatment. Methadone is the most tightly restricted drug in
the U.S. Doctors in general medical practice can't prescribe
methadone, and regular pharmacies don't distribute it.
The
most dramatic development in drug substitution and maintenance
is now underway in Switzerland. On July 10, 1997, the government
announced the results of a three-year experiment in which
800 heroin addicts were maintained on legal prescriptions
of heroin, and a much smaller number on injectable morphine
and methadone. The promising results of the Swiss trials have
led to ongoing pilot projects involving heroin maintenance
in Germany, Spain and the Netherlands. In December 2002, the
Canadian House of Commons Special Committee on Non-Medical
Use of Drugs called for ¡°proposed clinical trials pilot project
in Vancouver, Toronto and Montreal to test the effectiveness
of heroin-assisted treatment for drug-dependent individuals
resistant to other forms of treatment.¡± In Australia two
phases of a proposal to initiate a heroin prescription experiment
in the Australian Capital Territory (Canberra) were approved
in late July, 1997, but continue to face strong opposition
from some members of the government.
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