Subject: AIDS and the Heroin Connection Date: Published: 9/16/86 174 lines Source: Wall Street Journal. Copyright Dow Jones & Co. Inc. AIDS and the Heroin Connection --- By John Kaplan The enormous amounts of law enforcement and treatment resources spent trying to eradicate heroin addiction have only managed to achieve a stalemate in which heroin's costs to society have been kept relatively constant over the past decade. Recently, however, this uneasy balance has been disturbed by the appearance and spread of acquired immune deficiency syndrome. The exponential increase in this frightening plague has leveled off now, in great part because many homosexuals have changed their sexual behavior so as to greatly lessen their risk. It is now heroin addicts who are most threatened with the massive spread of the disease. It should not be necessary to point out that it is not in our interest to have AIDS spread among the addict population. First of all, heroin addicts are human beings and we do not impose the death penalty on their activities. Second, as expensive to society as the heroin addict is, he is much more so if he contracts AIDS; the medical costs of treating AIDS patients, even for a relatively limited time, are enormous. Finally, it is likely that intravenous drug users, being mostly heterosexual, will become a major conduit by which AIDS spreads to the rest of the population. We do not know much about the spread of AIDS through heterosexual relations, but we know it can happen -- and in this context it is ominous that a high proportion of female heroin addicts support their habits through prostitution. Obviously, the marked increase in the social costs of heroin addiction has public-policy implications. The most obvious option is to persuade addicts not to share their needles, thus preventing the major way that AIDS spreads among them. Such efforts have begun in numerous outreach programs, but we need to take the matter much more seriously. Addicts are typically much less middle class, forward looking, and respectful of authority than homosexuals and, hence, far more resistant to health education. After all, they already risk hepatitis and many serious infections through needle sharing, and risk death by overdose simply by shooting heroin. It is likely, too, that repealing our laws against their possession of "works" and even supplying addicts with sterile needles will have some effect. There is considerable opposition to such measures on the ground that they make it easier to become an addict -- an argument very similar to one that we should forbid seat-belt usage in an effort to make people drive more slowly. What we really must do, and do very soon, is increase the percentage of addicts in treatment. However, before we can make real progress in this we must get rid of certain illusions. Although methadone maintenance of heroin addicts does substitute one addicting drug for another, the drugs, from a societal viewpoint, are very different. In this context, the fact that methadone is taken orally is of vital importance. And, though non-drug residential treatment may be better for some addicts, it is much more expensive and most addicts are simply unwilling to put up with it. If maintenance is unavailable, they will remain untreated. In short, whatever its problems, maintenance on a long-acting, orally administered opiate is the most cost-effective treatment currently available for most heroin addicts. To some extent, we can reduce the requirements for admission to methadone maintenance programs; for instance, California is considering changing its requirement that before entering methadone treatment, an addict must have been addicted for at least two years and had two previous treatment failures. (The federal government, through the Food and Drug Administration, "merely" requires one year of heroin addiction.) The chances are that in view of the alternatives today, both state and federal requirements are much too stringent. In most places, however, the real problem is the shortage of slots in methadone programs. In many areas there is a wait of up to a year before an eligible addict willing to undergo methadone treatment can begin. Until then he, as a practical matter, is remitted to the needle. We must recognize, however, that in this time of reduced government resources, the chances are that major additional treatment resources will not be made available despite the urgency of the demand. As a result, we must do more with what we have. In part, we may have to rethink the effect of a decision inherent in government regulations that heroin treatment should include counseling, monitoring, and various other desirable but expensive additions. In a time when there are not enough places for those wanting treatment, it represents another example of the common governmental judgment that deprives us of a less satisfactory alternative because there is a better, though more expensive, way. It is the idea that since a Cadillac is better than a Chevrolet, those of us who can afford only the latter should walk. As long as there is a shortage of treatment slots, the waiting period for an addict willing to accept treatment in a maintenance program must be reduced. It has been proposed that private physicians perhaps under special license -- be permitted to prescribe methadone simply to maintain an addict until treatment in a program can begin. Though by no means as attractive to addicts as heroin, methadone is a drug of abuse and care should be taken to avoid its spread into the population. Nonetheless, unlike heroin, methadone is a comparatively slow-acting drug that is taken orally and, hence, an addict could take it quickly under minimal supervision in a doctor's office. Moreover, the street value of methadone is sufficiently low that it would not pay many addicts to make off with their dosages, even if they could do so. In addition, we know of two other drugs that may be more appropriate for this task. One is LAAM (levo-acetyl methadol), a synthetic opiate very much like methadone except that it lasts in the body for twice as long, making it even more convenient as a maintenance drug. Moreover, though many methadone users do report getting a slight "buzz" (which they enjoy) from their nightly dose, LAAM seems to be without this property and, hence, even less likely to cause abuse should it escape onto the street. In addition, a relatively new drug, buprenorphine, has a time course more like that of methadone but has the advantage that it is much harder to override with a shot of heroin. Those on methadone or LAAM can, and occasionally do, inject heroin. The importance of those maintenance drugs is that addicts are much less likely to develop a compulsive "run" of heroin use and will gradually use less and less heroin as their treatment progresses. Buprenorphine, moreover, has opiate antagonist properties that make it much less likely that addicts will take even occasional injections. Finally, being a safer drug than heroin or methadone, it is much easier to turn over for prescription by private physicians. Both LAAM and buprenorphine, when used for the maintenance of heroin addicts, are still classified by the FDA as experimental drugs -- but they are much closer to orphan drugs. No company seems much interested in fighting the bureaucratic battles to ensure that these drugs can be administered by private physicians in heroin treatment. There is also a place for increased law enforcement. Until we have a cure or preventive for AIDS, and until we can greatly reduce needle-sharing, the street-level heroin user represents a very different threat to the rest of us than he did in the past. As a result, we probably would be well advised to increase the amount of law enforcement -- at the very least against street-level sales, even if we do not impose criminal penalties for addiction and use themselves. Increased emphasis on the crimes addicts inevitably commit will have the effect of driving more addicts into treatment. And as if this will not be enough of a strain on law-enforcement budgets, we must regard prostitution, at least by those who may be AIDS carriers, as much more than a public nuisance. The urgency of this task is hard to overestimate. Already more than half the addicts in some treatment programs have AIDS antibodies. In a few years the damage may be done. Partly the problem is political in nature. Therapeutic communities have lobbied against the spread of methadone maintenance; methadone maintenance clinics have lobbied against the use of LAAM or buprenorphine by private physicians, and the Drug Enforcement Agency has historically fought against any changes making maintenance treatment easier. Nonetheless, state drug-abuse authorities, the FDA, the DEA, the National Institute of Drug Abuse, and local law-enforcement agencies can, working together, do a good bit to help -- but they will treat the matter with appropriate urgency only if the public demands it. --- Mr. Kaplan is a professor of law at Stanford University. He is the author of "The Hardest Drug: Heroin & Public Policy" (University of Chicago Press, 1985). (This article is made available here by Dow Jones Co. for the personal and non-commercial use of callers to this bbs, in the hope that it will be of some help to those who are suffering from the disease and others who are seeking to help them.)