A great entertainer overdosed on heroin two weeks ago. He was found dead, a needle hanging from his arm. Dozens of empty drug baggies were found strewn around his apartment.
He was considered a fantastic actor. Influential. Powerful. Insightful. Potent. Everyone, by this time, knows this man’s name. It’s been plastered across the media landscape not just in the United States, but worldwide: Philip Seymour Hoffman.
In the days since, there’s been all kinds of chatter about the evils of heroin or the need for better drug education. But there hasn’t been much talk about the painful, obvious, cold, hard truth: Heroin should be regulated—and not only because science says so, but because, (and again, let’s be honest) look around.
Drug prohibition didn’t keep us from this great cultural loss. In fact, drug prohibition causes thousands of unnamed human losses we suffer day after day, month after month, year after year in this country. Think of the person you know (or your friend who knows someone) who has died because of a heroin, or opiate, overdose. Say their name—because they deserve to be remembered, as much as Hoffman does. And because in a health-centered, rather than law enforcement-centered, world, they didn’t have to die.
According to the Center for Disease Control, “opioid analgesics, such as oxycodone, hydrocodone, and methadone, were involved in about 3 of every 4 pharmaceutical overdose deaths” and “38,329 people died from a drug overdose in the United States in 2010.” According to the Office of National Drug Control Policy, from 2006-2010, that was a 21% increase.
Death by heroin increased 45 percent during the same time frame.
Allan Clear is executive director of the Harm Reduction Coalition, a non-profit organization that advocates for injection drug users in the United States. When I contacted Clear to comment, he started by reviewing Hoffman’s history. “He had problems when he was younger, got help, then he was using pills, then he switched to heroin,” Clear noted.
In fact, pharmaceutical drugs like Oxycontin that are one of the primary reasons we have an opiate addiction crisis in the U.S. in the first place.
“A fantastic amount of [pharmaceutical] drugs get out there,” said Clear. “Cutting back on prescribing can help. Part of the problem is that opiate drugs are out there in too vast quantity. The reason we have a pain pill problem in this country is because of the historic under treatment of pain. Now we have over prescribing.”
The pharmaceutical-to-heroin transition is often made when one’s opiate prescription ends or is no longer covered by insurance, whether you’re rich and famous or poor and on Medicare.
“If we had a maintenance program,” Clear continued, “his dependence would’ve been managed by the medical community, and he wouldn’t have needed to graduate to street heroin.”
Maintenance? That’s a program where pharmaceutical, clean heroin (or other opiate) is administered in a controlled, clinical setting to addicts who have not benefited from other, more traditional treatments such as methadone.
“The advantage is he can understand what’s going into his body and what his dosage should be,” said Clear. In addition, “He doesn’t have to run out and buy drugs, so it’s not a struggle. It takes away anxiety. That kind of constancy and quality control would begin to mitigate some of the adverse reactions to heroin.”
In other words, had Hoffman been on heroin or opiate maintenance (if we had such a thing in the United States), it would have been clean, pharmaceutical grade—not cut by unknown drugs—the dose he took would have been known. It might not have killed him, and he would’ve had medical support throughout the process, so in case of an emergency, he might have been saved.
But many people believe that “there is no safe batch of heroin. It’s a killer drug,” as Boston mayor Martin J. Walsh recently said. While that is true of street heroin, where the shadowy dealer is in control, it’s not true of a pharmaceutical, medical care system of dealing with opiate addiction, such as Clear suggests.
Alex Wodak is President of the Australian Drug Law Reform Foundation. He points to a mountain of evidence that heroin maintenance is cost effective and better for the public health than law enforcement-centered prohibition, calling it “an evidence-based drug policy, rather than the fantasy-based drug policies of the United States.”
“The threshold issue is redefining drugs as a health problem,” Wodak said. “Once that switch is made, then most of the funding has to increase via health and social investments. Investing money in law enforcement is a waste of time.”
Thomas Kerr, Associate Professor in the faculty of medicine at the University of British Columbia, has run several NIH-funded studies of injection drug users. He’s also one of the lead scientists evaluating Vancouver’s supervised injection facility, Insite. (A supervised injection facility is a place where addicts can take their drug, under the supervision of medical personnel. The site doesn’t offer illegal drugs—they simply provide a clean, safe environment, so the person isn’t using dirty needles or if they OD or want help medical staff is on hand.)
One of the major benefits of a regulated drug market, Kerr said, is “you can be assured of the dose and purity. So many deaths happen as a result of lack of knowledge or purity. Sometimes the heroin can be cut with impurities that make people sick. When people are consuming a drug that is illegal and they are marginalized for their use, they don’t know the purity or strength.”
By keeping these drugs illegal, and forcing people to turn to an illegal market, “we are causing more harm than the drugs themselves. Imagine every time you wanted to have a drink, you had to go to an unknown source, and every now and then, you got alcohol that contains paint remover. It would burn your esophagus and you’d need to be hospitalized. It seems crazy and makes no sense. But we’ve tolerated that with drugs like heroin.”
There have been numerous heroin trials around the world, including Spain, Switzerland, the Netherlands, Germany, Canada, and England says Kerr, and they show that “when you provide people with pharmaceutical heroin, they can return to work, reduce their involvement in criminal activities, and reduce their illicit use.”
Additionally, “We’re not talking about a one-off, poorly conducted study. There have been numerous trials conducted in multiple countries with the same results. There is no academic debate about the value of prescribed heroin. It’s really a political and ideological debate rooted in an archaic system of drug and law control. That in turn creates stigmatizing and discriminating. The WHO [World Health Organization] agrees this is a health issue.”
But others argue that heroin maintenance does nothing more than use taxpayer money to support, or even encourage, addiction. Calvina L. Fay, Director of the Drug Free America Foundation, reports, “Most opiate addicts are polytoxicomaniacs (addicted to several drugs) and [heroin maintenance] programs would supply them with their base drug, free of charge… Psychic effects of opiates make it very difficult to get in touch with the addict emotionally; therefore, psychotherapy is almost impossible… [and] A patient in a heroin maintenance program is still under the influence of the drug and has no motivation to begin a therapy leading to abstinence.”
The United States might seem quite far away from heroin regulation. But there are other tweaks to attitude and policy that can be made.
Coming out of treatment, Clear said people “should be prepared for not only how they remain not using, but they need to be equipped for what to do if they decide to pick up again—Or if someone they come across is.”
This can include making anti-addiction drug buprenorphine available to them, as well as anti-overdose medication naloxone. “In France, they vastly expanded buprenorphine and the overdose rate fell,” said Clear. “It’s still not as widely used as it could be. Someone who has that history should have that option—and there are not many treatment facilities in the United States that go that route. [It] can be a lifesaver. I’ve known people who have a history of using, when they know they’re going in to a situation [where they might want to use heroin], they take 2-4 milligrams of buprenorphine, to make sure they don’t pick up.”
In other circumstances, naloxone (also known as Narcan) might work. It’s an injectable drug that saves people from dying from heroin overdoses by knocking the opiates off the receptors in the brain—so the person overdosing starts breathing again. (That’s frequently how heroin overdoses kill: the person stops breathing.) “It’s a weird thing to say,” said Clear, “but it is a miracle drug. You have a person who is turning blue and dying, and you give them this drug, and they’re breathing again. Suddenly, they’re not high. If I were to take it with no opiates in my system, I’d have no adverse reaction to it. It’s completely safe.” Yet the availability of the drug, which Clear says should be made available to everyone leaving opiate treatment, is patchwork across the country. Some jurisdictions allow family members of addicts to have it. Others permit only the police and EMTs to carry it. Boston Mayor Walsh just announced all Boston police and EMTs will now carry it after three people died of heroin overdoses in just 48 hours.
It all comes down to “rethinking the way that we utilize medication,” said Clear.
There’s “also as a protective factor when it comes to overdose. We have a tightly controlled clinic system that isn’t convenient for people. Then we have the criminal sanctions, which leads to secrecy. So many people have had their lives destroyed, especially people of color… Those sanctions make it harder to come above ground and seek support, when you don’t know what the consequences are.”
“There are many scenarios where someone overdoses, and the people they are with leave because they are afraid,” Clear continued. “People have been charged with murder for supplying the [injection] that kills them. Just taking the criminal justice system out of it would be a major step forward.” Hence, the need for more “good Samaritan” laws that protect people who call for help when someone is overdosing.
Clear also says that the popular idea in the treatment industry—the idea of anonymity, “is a bit of an issue. It would be helpful if people knew how many had these issues, because it makes it less of an issue when so many people have the issue.”
Prescription drug Dilaudid, said Clear, (as well as others interviewed for this article), is another solution. An addict could be prescribed Dilaudid with out the stigma and resonance that a drug like heroin carries with it.
Many advocates say public health approaches such as these are big step towards ending the stigmatization of drug users, and say that by removing criminal sanctions and improving access to health-oriented programs, the addicts can stabilize their lives and reduce their involvement in crime.
Others like Fay say that even funding needle-exchange programs is a waste of resources. In Denmark, when there was a heroin maintenance initiative, the opposition to the idea also came from those who had concerns about funding.
And of course not all maintenance programs are created equal, and the opiate addiction drugs we already use regularly, such as methadone, have their problems, too, including being difficult to detox from. Many neighborhoods dislike having methadone clinics in their communities, often because of how the methadone is distributed: the addicts must show up at the clinic every day for their dose, frequently lining up outside, to the disdain of neighbors.
Robert Hämmig, medical director in the addiction department—Bern University clinic for Psychiatry & Psychotherapy, and President of the Swiss Society for Addiction Medicine, said that in Switzerland, the same NIMBY problem happens with the heroin clinic there, too, because the addicts cannot take their dose home, so they stay nearby in order to take their dose twice a day, 365 days a year. The most severe side effect some users experience from heroin maintenance is osteoporosis after long-term use. Other than that, says Hämmig, the social side effects of it are related to how it is restricted—such as the lines of people outside the clinic.
Legalization of prescription-based opiate maintenance probably will not eradicate the black market, either.
Still, “It’s time for a shift,” in policy, said Kerr, especially now that “people realize the system of control and punishment is the worst policy.”
Nearly 100 years ago, after all, heroin maintenance was legal in the United States.