The heroin trial we had to have
Viewpoint: the climate of prohibition has prevented dispassionate scientific assessment of the trial
MJA 1996; 164: 694-695
That we treat heroin as a special drug is one of the great anomalies of
this dark age of drug prohibition and the so called "War on Drugs". This
is the one-sided policy that attempts to reduce consumption of
illicit drugs by reducing supply through interdiction and
incarceration. The war is being waged by policy makers, law
enforcement and the military throughout the world. The effects of
this social policy pervade the daily lives of all citizens, whether
they know it (through the drug-related death of a friend or relative or
through being burgled) or not (through taxes which pay for the
imprisonment of drug users or through increased insurance premiums
because of drug-related crime). It is scarcely credible in this era of
sceptical rationality that a social policy with such far-reaching
effects is based on little more than an almost religious faith in the
doctrine of prohibition -- a policy based on racism, commercial
exploitation, colonialism and the worldwide export of United States
domestic policy.1 The proposed trial of
medical prescription of heroin to heroin-dependent people in the
Australian Capital Territory (ACT) would provide important data for
more informed decision-making about heroin policy.
Prohibition has the effect of demonising heroin and dehumanising heroin users. Objections to limited, scientific attempts to obtain information for rational debate about the best, least harmful method of integrating heroin and other opium use into our society eventually derive from the absolute need to defend the essentially untenable position of prohibition. Such objections have been vigorously raised about the proposed ACT trial. Were the proponents of prohibition sure of their position, they would have nothing to lose from such trials, which could adduce only further evidence of the need to direct every effort towards abstinence.
On the other hand, objections to the proposed methods of the trial need careful consideration. Objections that the trial will not answer multiple questions about heroin use and treatment overlook the specificity of its aims. Indeed, the modest aims and careful development of realistic outcome indicators are outstanding features of the proposed trial.
Equally, the objection that such a trial will equate to, or advance, the legalisation of heroin is fundamentally flawed. The medical prescription of heroin to those who are heroin-dependent maintains the current problematic view of heroin use -- the problem is simply medicalised. This, I would argue, is actually a retrograde step for legalisation, as medicalisation will make medical (rather than legal or moral) arguments paramount and very difficult to counter. We should have sufficient experience with methadone maintenance treatment to recognise this, but the voice of the methadone consumer has generally been silenced. For instance, maintenance therapy is often justified and used as a form of social control, particularly for reducing crime by heroin users, while masquerading as a medical treatment.
There should, of course, be multiple options for those dependent on opiates and having trouble with this dependence. One option is oral methadone and others could include injectable heroin and buprenorphine. Each needs careful, controlled scientific examination; this is extraordinarily difficult in the context of prohibition, which creates so many confounders (e.g., necessary involvement of the heroin user in a criminal milieu, enormously inflated cost of drugs on the black market and resulting peer pressure to participate in crime).
Information from properly planned and conducted scientific research is desperately needed to underpin policy and treatment approaches; the ACT trial will clearly provide a very important piece of this information. It would enable us (as a society) to assess the best methods of delivering injectable heroin in cooperation, rather than in competition, with other substitution approaches. It is an unfortunate reality that the ACT researchers must operate within a prohibitionist framework. Although prohibition has been shown to be harmful,2 legalisation has not as yet been convincingly shown to be less harmful. This needs an incremental approach, an adducement of evidence until the balance of judgement is swayed from supporting prohibition to regulation.
The ACT researchers must be in a bind about the cost of the trial. On the one hand, the trial and its results will be so intensely scrutinised that it must be, and be seen to be, totally credible scientifically. This is expensive and leads to the charge that one small trial, on one small aspect of our relationship with heroin, will expend an inordinate proportion of our drug research budget. The researchers have made it clear that funding for the trial must be "new" money, raising the question of the trial's viability in the current political climate. However, the potential returns are so great as to outweigh this objection -- few other areas of research are likely to return so much, especially by attracting a wider range of the heroin-dependent into treatment that is cheap in comparison with imprisonment.
The issue of morality often underlies the arguments. Moral arguments have their place, but are meaningful only when based on accurate information. The morality that rejects a place for opiates in this society because they are dangerous, when the danger demonstrably comes more from their illegality than from the drugs themselves, is flawed. I have often pondered why it is heroin that we have demonised and suspect that such violent reactions must be extremely attractive to those waging the War on Drugs. The obverse of approaches considered to "condone" heroin use are those which make it as dangerous as possible. It is a strange morality which argues for so many deaths to prevent the use of a substance that is relatively harmless under controlled conditions -- a morality that has given us enormous epidemics of HIV infection among children of heroin users in the United States and elsewhere. This is a morality which I suspect most people would not support without the intense social conditioning of the War on Drugs.
The proposed trial would not provide all the information about heroin that is needed as a basis for public policy. It cannot, and should not, tackle holistic questions about the "best" (least harmful, most beneficial) relationship between heroin and society. Answering these questions needs data on more than the medical aspects of the relationship. However, this trial will provide some key data; what more should be required from a single study?
Epidemiology and Social Research, Macfarlane Burnet Centre for
Medical Research, Melbourne, VIC.
Nick Crofts, MB BS, MPH, FAFPHM, Head.
No reprints will be available from the author.
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