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Maximilian Ehrman Harm Associated with Intravenous Heroin Abuse and the Current Status of Harm Reduction Programs in the United States

Although opium use has been documented for thousands of years, the advent of the hypodermic syringe in the 1850s and discovery of heroin in 1895 revolutionized how addictive and dangerous recreational drug use can be. Consuming a drug orally, whether medicinally or recreationally, is a natural process because there is a barrier between the body metabolizing the drug in the liver and the drug reaching the brain. Intravenous injection, however, provides direct access to a persons bloodstream. It is a synthetic and foreign mechanism for administering drugs. A person intravenously injected with a drug can feel the effects in seconds. With regards to heroin use, intravenous injection is a tremendously reinforcing and potentially lethal act because of the near immediate response it provides alongside the risky complications it threatens. Under prime conditions of sterile syringes, pure drugs with an established mechanism of action and administration by a medical professional, intravenous injection of a drug is considered a safe procedure and is well understood. However, intravenous drug users (IDUs) dont always have access to sterile syringes, are not medical professionals and rarely use pure drugs. This presents a plethora of problems for those who choose to inject heroin intravenously. In response to the harm involved with heroin use, laws were passed across the globe banning the substance and incriminating those involved. The intent of these laws was to deter heroin use in the hope of saving lives. However, as with most objects deemed contraband, the trade and use of heroin continued as there was adequate demand for the product. Citizens of the United States were told to Just Say No, and a war on drugs was declared. Drugs were

portrayed as the enemy, something evil. A consequence of this was that drug users were seen in black and white. Either one was an amoral addict, or a moral abstainer. While the motif behind these campaigns was noble, they did not take into account the reality of the situation. Humans use drugs, enjoy using drugs, have used drugs for thousands of years and will continue to use drugs even at the risk of harming their health and incrimination. While conventional treatment philosophy demands abstinence, the treatments that utilize a harm reduction philosophy simply have the goal of minimizing the harm associated with highrisk behaviors. Regarding drug users, it accepts them as they are, without any assessment on their morals. Alan Marlatt, a pioneering researcher in this field, eloquently stated that harm reduction tells users to come as you are (Marlatt, 1996). This is counter to the war on drugs notion of abstain or be damned. Harm reduction is a philosophy that does not judge what people do, nor does it tell them what to do. It simply promotes that whatever people do, should be done in the safest manner possible. Examples of harm reduction programs for drug use include needle exchange programs, supervised shooting galleries and maintenance programs. Needle exchange programs provide users with access to sterile syringes and other equipment involved in intravenous drug use. IDUs are also taught the proper mechanics involved in intravenous injection. Shooting galleries are designated locations where IDUs can inject drugs in a safe environment under the supervision of a medical professional and without fear of indictment. Maintenance programs provide severely addicted users, whose withdrawal symptoms are so debilitating, with a daily dose of their drug of choice or a functionally equivalent substitute. These programs enable IDUs to better function in society by not being in physical withdrawal.

The purpose of this paper is to show why the United States should be proactive in implementing more harm reduction programs. Prior to understanding why the United States should be proactive in implementing a more harm reduction centered approach to their current drug policy, knowledge of heroin and the harm encountered by IDUs is necessary. The paper is composed of the following sections: overview of opiates and heroin; physical and social consequences faced by IDUs; assessment of harm reduction programs; final thoughts. This paper will focus on intravenous heroin users specifically; IDUs and intravenous heroin users are used synonymously unless otherwise noted. Opiates Opioids are drugs that bind or have an affinity to the many opioid receptors located in the central and peripheral nervous system and the gastrointestinal tract. Drugs considered opioids can be natural, semisynthetic, synthetic or endogenous. Natural opioids, specifically referred to as opiates, are derived from the poppy plant Papaver somniferum and include morphine and codeine. Semisynthetic or synthetic drugs such as heroin, hydromorphone, oxycodone and methadone are referred to as opioids. Peptides produced by the body that bind to opioid receptors are known as endogenous opioids (Simon, 1992). Opioids and opiates can be agonists or antagonists to opioid receptors. When an opiate agonist is taken, it binds to opioid receptors, causes an action and triggers a response, while an antagonist blocks the action of an agonist. For simplicity in this discussion, the term opiate will be used to describe all known chemicals that are agonists to opioid receptors unless otherwise noted (Simon, 1992). Opiates have long been used for their analgesic properties with recorded use dating back to 3000 B.C.. Opioid receptors, however, are now known to be involved in a variety of physical

systems and mental states that include subjective mood, mentation, and pain as well as sedation, respiratory depression and constipation. The subjective experience of taking an opiate is increased analgesia, sedation, lethargy, and euphoria. Constipation occurs when taking an opiate due to the presence of opioid receptors in the gastrointestinal track. Opiates are widely used in contemporary medicine for acute or chronic pain, as anesthesia for surgery, as well as for treating depression, insomnia and diarrhea. Recreational use of opiates is primarily for their euphoric properties (Simon, 1992). Opiates are addictive substances. Continuous use of opiates leads to tolerance and physical dependence. A physically dependent opiate user is characterized by having a pronounced tolerance to the drug and upon ceasing use, experiences physical and psychological withdrawal. Referred to initially as morphine abstinence syndrome, symptoms an individual endures while withdrawing from opiates include restlessness, muscle and bone pain, insomnia, diarrhea, cold flashes, irritability, yawning, goose bumps and an intense craving for opiates (National Institute of Health, 2010). The intensity of these symptoms is directly correlated with a users dosage (Andrews & Himmelsbach, 1944).

What the Body Does to Opiates and What Opiates Do to the Body
A drugs pharmacokinetics, or what the body does to that drug and a drugs pharmacodynamics, or what the drug does to the body are critical in evaluating a drugs pharmacology. Opiates are assessed by their affinity to the opioid receptors, bioavailability, peak plasma concentration, half-life, active metabolites, and lipid solubility. Each of these is important in determining an opiates potency, time of onset, length of activity, and abuse potential. Affinity, a term used to describe how well an opiate binds to receptors is correlated with potency (Simon, 1992). An opiate that has a greater affinity is generally a more potent opiate.

Bioavailability describes how much of a drug administered reaches the bloodstream and ultimately the brain. Dependent on which drug is given and by which route the drug is administered, bioavailability is an important concept in understanding why heroin injected intravenously is especially addictive and reinforcing. While a drug administered intravenously has a 100% bioavailability because it goes directly into the bloodstream, that same drug taken orally may have a lower bioavailability because it gets metabolized by the liver prior to entering the bloodstream. Metabolization by the liver, referred to as first pass metabolism, grants the body a buffer when absorbing chemicals, and is why drugs taken orally typically have bioavaibilities of below 100%. For example, if a 50 milligram(mg) oral dose of a drug with an oral bioavailability of 50% is taken, 25mg will reach the bloodstream and ultimately the brain. If that same drug were taken intravenously, the entire 50mg will reach the bloodstream. Regarding heroin, the complete absorption of an intravenous injection is one of the reasons that users who have tried this route exclusively abide by it. Peak plasma concentration refers to the time after administration where the highest concentration of a drug is present and is largely dependent on the route of administration. Interestingly, recreational opiate users report highest scores of euphoria during peak plasma concentration. When comparing two routes of administering opiates, the route with a faster peak plasma concentration has an increased abuse potential because it is felt quicker and thus is more reinforcing (Rook et al., 2006). Regarding heroin, why an intravenous injection rivals all other routes of administration in subjective scores of euphoria can be explained by its near instant peak plasma concentration. A drugs half-life is the amount of time it takes for the concentration of the drug in the bloodstream to half. The half-life of a drug is indicative of how long it retains a pharmacological

effect on the body. The longer the half-life, the longer the effects of the drug last. Some opiates, however, are pro-drugs, meaning they do not have a direct affinity to opioid receptors, but exert their effect after being metabolized by the body and changed into a drug that is active. Heroin is an example of a pro-drug and its pharmacokinetics will be discussed shortly (Simon, E.J. 1992). An opiates lipid solubility determines how well it can cross the blood-brain-barrier, reach the brain, bind to the opiate receptors, and exert its effects. Increased lipid solubility is correlated with a faster onset and an increased abuse potential (Rook et al., 2006).

Pharmacology and Pharmacokinetics of Heroin


The Bayer Company synthesized heroin (diacetylmorphine), a semisynthetic opiate agonist, in 1898, hoping to create a treatment for morphine addiction. Unbeknownst to Bayer was that heroin is a pro-drug for morphine, has a very short half-life, and due to its increased lipid solubility, crosses the blood-brain-barrier more effectively. These pharmacokinetic qualities make heroin a fast acting potent opiate and more addictive than morphine (Simon, 1992). As described previously, the recreational quality of opiates is primarily due to the euphoria felt after ingesting them. Heroin is described as the most euphoric opiate and is currently one of the most well-known addictive substances. An estimated 23% of individuals who try heroin a single time become addicted and habitually use (National Institute of Health, 2010). The subjective experience of an intravenous injection of heroin is extremely pleasurable, rewarding and reinforcing; IDUs describe it as a "wave of euphoria," or a "rush." Other routes of administration such as inhalation or intranasal are pleasurable and reinforcing, but wane in comparison to intravenous injection due to lower bioavailability and slower peak plasma concentration (Comer & Zacny, 2005).

The bioavailability of heroin is dependent on the route of administration and the type of heroin procured, as there are different kinds of heroin and different ways of administering it. Heroin purchased illicitly in the United States can come in a powder referred to colloquially as china white or as a black substance with a gooey consistency known as black tar heroin. There are several ways of synthesizing heroin and the difference in appearance and quality between these two types is based on how they are manufactured. Figure 1 provides an image of both kinds. Both varieties of heroin available in the United States can be injected intravenously, intramuscularly, and subcutaneously. Intravenous injection is the superior method of administering heroin. It has a 100% bioavailability and a near instant peak plasma concentration. Intramuscular and subcutaneous (under the skin) injections of heroin are not typically desired and are usually the result of an unsuccessful intravenous injection. By analyzing the concentration of heroins main metabolite morphine in the blood plasma, intramuscular injection of heroin has an estimated bioavailability of 34% (Girardin et al., 2003). There is no current publication on the bioavailability of heroin injecting subcutaneously. Heroin in the form of black tar can be vaporized and inhaled. Inhaling the vaporized fumes of heroin is known colloquially as chasing the dragon. The process of inhaling heroin uses aluminum foil, a flame, and a straw. Heroin is placed on aluminum foil, a flame is ignited underneath the foil, and the heat of the foil causes the heroin to vaporize into a gas that is then inhaled through a straw. Heroin used this way bypasses first pass metabolism by the liver. Bioavailability of heroin inhaled is estimated to be 52%. It has a very fast peak plasma concentration and the effects can be felt within 1-2 minutes (Rook et al., 2006).

Powdered china white heroin can be administered through the intranasal route. Known as snorting, users will inhale powdered heroin into their nose, where it is rapidly absorbed through the mucus membranes into the bloodstream. Intranasal bioavailability is estimated to be 50%. It has a fast peak plasma concentration and effects can be felt within 15 minutes (Hendriks et al., 2001). Less common routes of administering heroin are taking it orally, or rectally. When taken orally, heroin goes through first pass metabolism in the liver and has a low bioavailibilty. In addition to a low bioavailability, heroin taken orally does not produce the euphoric rush desired by users due to the oral route of administrations lengthy plasma concentration; orally administered heroin does not exert its effect until it is metabolized by the liver and enters the bloodstream, a process that can take up to two hours. Heroin taken as a rectal suppository gets absorbed through the mucus membrane in the rectum into the bloodstream. It has a bioavailability equivalent to oral administration but is scored as significantly more euphoric than an equivalent oral dose due to its faster peak plasma concentration (Rook et al., 2006)

Figure 1. On the left is black tar heroin; notice its thick consistency. The china white heroin on the right is in a powdered form. The difference between these two types of heroin is their method of synthesis.

Harm Associated with Intravenous Drug Use


The method of preparing heroin for intravenous injection is dependent on the type of heroin used. The processes described here were obtained from Erowid (2011). For powdered heroin, the process uses a syringe, water, a small container or cap and a filter. First, the powdered heroin is emptied into a cap with a small amount of water. This mixture is then stirred until its a homogeneous liquid. A filter, typically a small amount of cotton, is then placed in the mixture and a syringes needle is inserted in the filter. The needle is pulled and creates a vacuum that sucks the heroin mixture through the filter into the syringe. The needle is then inserted into a vein where it can finally be pushed and injected. It is important to note that a proper insertion is typically confirmed by the presence of blood caused by a user pulling back on the needle just prior to injecting. The absence of blood would inform the user that the needle was not properly inserted and that a readjustment is necessary for an intravenous injection. Black tar heroins thick consistency necessitates an additional step before it is injected. When the heroin is in a cap with water, a flame is ignited underneath. This heat source ensures that the mixture is homogenous and suitable for injection. Afterwards, the same steps of filtering, sucking and injecting follow. The heating of black tar heroin is why spoons are commonly associated with IDUs. They are used as caps because they can be easily heated by igniting a match or lighter underneath them. IDUs can be unsterile during this act by using dirty water or by foregoing on filtering. There are, however, harm reduction practices that IDUs can add to their injection routine that make it safer. These include using sterile distilled water, a wheel or micron filter, and prepping an injection site with alcohol. These will be discussed in later chapters.

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There are many problems associated with intravenous heroin use that compromise an IDUs physical, social and legal wellbeing. Bacterial infections, fatal overdose, HIV, Hepatitis C, and collapsed veins are just some of the physical harm encountered by IDUs. Interpersonal and intrapersonal harm include housing and job complications, convictions from law enforcement, poor social support, and stigmatization from society. This section will outline the harm associated with intravenous drug use in the following manner: Harm encountered by how much one uses, harm encountered by how one uses, harm encountered when one is physically dependent and interpersonal & intrapersonal harm associated with heroin use.

Harm Encountered by How Much One Uses


Harm encountered by how much heroin one uses presents the most immediate danger to IDUs because of the risk of a fatal overdose. Signs of heroin toxicity are severe respiratory depression, coma-like state, and constricted pupils. A heroin overdose is a medical emergency where an opiate antagonist such as naloxone must be administered to counter the effects of heroin. An examination of drug related fatalities in Britain found that 53% of heroin-related deaths were attributed to direct acute overdose (Webb et al., 2003). Other causes of death among heroin users such as disease and trauma will be discussed in later chapters. Currently, there is controversy regarding what precisely a heroin overdose is. This is because a post-mortem toxicological examination for morphine, which is the main metabolite of heroin, has sometimes shown at being below the toxic level of 461mg per kg. Also, when comparing IDUs who died of an overdose to IDUs who died for reasons other than an overdose, or even to IDUs who are alive, their respected morphine concentrations overlap. These proponents for stricter guidelines defining what a true heroin overdose is suggest that polydrug-

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use, involving other central nervous system depressants, such as alcohol or benzodiazepines is the true culprit behind the majority of heroin overdoses (Darke & Zador, 1996). This paper will define heroin overdoses as Webb et al. (2003) do: Overdosedeath directly related to an episode of toxicity. For example, where cause of death is given as the physiological effects of the substance implicated or its direct consequences. Circumstances Conducive for an Overdose The lack of standardization amongst heroin procured illicitly presents IDUs with a vague knowledge regarding how much they use. Sampling of heroin has produced wide ranges in purity ranging from 13.2%-79.8% (Darke, Hall, Weatherburn, & Lind, 1999). In addition, the amount of heroin in these bags can differ dramatically. While IDUs may describe their usage in terms of how many stamps (typically 100mg $10 vials or bags of heroin) they use daily, the amount and relative purity of the heroin they obtain is unknown. For example, if an IDUs average daily heroin intake consists of five bags and unbeknownst to that user, the bags they obtain on a particular day contains more or a purer quality of heroin than average, that IDU may use a significantly larger amount of heroin than anticipated, increasing their risk of a fatal overdose. Tolerance, the decrease in effect of a drug due to prior use, is a long withstanding principle in drug addiction. With subsequent use, IDUs who initially found one or two bags of heroin sufficient may soon find the need to increase their intake to achieve the same effect. Reversibility is a principle of tolerance that can play an important role in fatal overdoses. If IDUs abstain from using whether by choice (colloquially known as a tolerance break) or by force (treatment or incarceration), upon using heroin again, they would find the necessary dose to achieve the desired effect to be significantly lower. This phenomenon is occasionally induced by IDUs for monetary reasons by choosing to abstain from using heroin for a set period of time with

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the goal of the tolerance break being a decrease in the amount of heroin required to achieve their desired effect in the future. Due to the reversibility of tolerance upon abstaining from use, IDUs have an increased risk of a fatal overdose after release from prison for up to four weeks (Merrall et al., 2010) and an increased risk of a fatal overdose for up to four months after completion of a treatment program (Strang et al., 2003). The following is a fictionalized example of this phenomenon:
Tom is a homeless IDU with a 5-year-long addiction to heroin. His strong addiction requires him to use several bags of heroin a day to keep his withdrawal at bay. Being homeless and having no steady source of income, Tom resorts to pan handling to acquire the necessary funds to obtain his heroin. After a police officer sees Tom and deems him a public nuisance, he subsequently arrests him for loitering; while not by his own volition, Tom abstains from using heroin during his two-week jail sentence. Upon his release from jail, Tom eagerly acquires a seemingly normal amount of heroin but unbeknownst to him, his tolerance significantly lessened during his two week abstention and after he injected what he thought was a typical amount, he suffers a fatal overdose.

Harm Encountered by How One Uses


While this paper focuses on heroin administered intravenously, many heroin users do not utilize this route. A longitudinal study in New York City reported that intranasal use was the primary route for 25% of users sampled in 1988, and 59% of users sampled in 1998 (Neaigus et al., 2006). These data are encouraging, as intravenous injection is significantly riskier than intranasal administration due to risks in contracting blood-borne viruses and bacterial infections. It is important to understand how the transition of becoming an IDU from a non-injecting user occurs because of the increased risks of injecting intravenously. Studies have found that the transition is largely influenced by a users social network, their individual susceptibility and their history regarding intravenous injection (Neaigus et al., 2006). Non-injecting users who injected in the past are known to be significantly more likely to transition back to injecting than a user who never has. Physical factors influencing a non-injecting heroin user to become an IDU

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include the current purity, availability and price of heroin, and the strength of a users dependence. Social factors include how many IDUs are in a users social network, their perceived status of IDUs, their knowledge on blood-borne viruses rampant in the IDU population, and their comfort level in using syringes (Neaigus et al., 2006). A common scenario involving a habitual IDU is that initially they start by intranasal or inhalation ingestion. Subsequent use increases their tolerance to the drug and they require more heroin to achieve their desired effect or keep their withdrawal at bay. Then after trying an intravenous injection and noticing the decrease in heroin needed, compared to their previous method of ingestion, they strictly abide by it. The following is a fictionalized example articulating this progression:
Mary, a 19-year-old student, was first introduced to heroin at a party. People at this party were using heroin by inhalation or chasing the dragon. This method of ingestion was placing heroin on a sheet of aluminum foil, igniting a flame underneath the sheet, and then inhaling the fumes the vaporized heroin produced. After this introduction, Mary was inhaling heroin daily for several weeks and was severely addicted. Her frequent use cost several hundred dollars a week as her savings and stipend from parents rapidly depleted. One time as she purchased heroin from her dealer, she asked if she could smoke in their apartment. Her drug dealer replied that she is wasting money by smoking and she should inject it. After a brief hesitation, Mary follows his suggestion and injects a third of her average inhaled dose intravenously. She finds the effects far superior to her previous method and strictly uses this method thereafter.

Problems regarding intravenous injection which is known colloquially as mainlining, slamming, and shooting arise because most IDUs do not have training in how to properly administer drugs intravenously. This ignorance leads to unsafe practices such as not filtering, using unsterile water, reusing old syringes and sharing syringes with other IDUs. Reusing and sharing syringes is common amongst IDUs and it leads to an increased risk of infection and vein complication. In an assessment of IDU habits, only 36% of IDUs of all

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drugs reported consistently using new syringes for each injection in the past week, and over onethird reported sharing a syringe in the past 6 months (Gagnon & Godin, 2009). By injecting the drug intravenously with shared or used syringes, IDUs run a great risk of collapsing their veins (Atkinson et al., 2003), contracting HIV and Hepatitis C (Rich, Macalino, McKenzie, Taylor, & Burris, 2001), and becoming infected with abscesses, cellulite and potentially fatal endocarditis, (Tomolillo, Crothers, & Aberson, 2007). IDUs typically use 29-31 gauge insulin syringes. These syringes are specifically designed for single use. When repeatedly used the needle of the syringe becomes increasingly dull (See Figure 2 for an illustration). When a dull syringe is injected, it irritates the vein and causes it to swell which may then temporarily block the circulation within the vein. This blockage is referred to as phlebitis or a collapsed vein (Mayo Clinic, 2011). Given time, a collapsed vein will heal and circulation will resume but long-term use may permanently block off a veins circulation. In addition to phlebitis, a syringe used multiple times increases the risk of injecting bacteria into the bloodstream. This also occurs upon removing a needle after a failed injection. When a needle is removed from the body, latent bacteria on a users skin can become attached to the needle. When this infected needle is used, the bacteria present on the needle can enter the bloodstream and cause an infection. A common practice amongst IDUs is to constantly switch their injection site to allow collapsed veins to heal and remain intact. However, after heavy use, IDUs may find it increasingly difficult to find a suitable vein for injection. In this scenario, after their primary injection site (typically the forearm) has collapsed, IDUs will search for viable veins located elsewhere, typically moving from their forearm to their hand, then to the legs, and then to the feet. IDUs may eventually exhaust all visible veins on their body. Desperate IDUs have been

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known to inject into areas on their neck and on their genitalia, increasing their risk of complications dramatically (Darke, Ross, & Kaye, 2001). After an IDU exhausts all visible veins, riskier methods of injection such as intramuscular (muscle shots) and subcutaneous (skin-popping) follow. The subcutaneous environment is better suited for bacteria to reproduce and IDUs who skin-pop by injecting subcutaneously are at a greater risk of contracting infections than those who mainline and inject intravenously (Binswanger, Kral, Bluthenthal, Rybold, & Edlin, 2000).

Acquired from http://farm4.static.flickr.com/3221/2328527271_5e2fd3f25e.jpg

Figure 1. Notice how after even one use a syringes tip becomes dull and bent. IDUs who have poor injection techniques may attempt to inject intravenously but fail to enter a vein and retreat before injecting. They may repeatedly use a single syringe until a vein is hit with each failed injection causing damage to their body.

Infections

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First noted in 1933 by a researcher seeing a significant correlation between prisoners who administered drugs intravenously and malaria infections, the hypodermic syringe unintentionally allows potentially fatal parasites, bacteria and viruses direct access to the body (Himmelsbach, 1933). Bacterial Infections Local bacterial infections such as abscesses or cellulitis are widespread amongst IDUs, with prevalence rates ranging from 25%-68% (Binswanger et al., 2000; Haverkos & Lange, 1990). Presented in Figure 3, these infections require medical attention to treat or serious complications may occur. An abscess is a localized collection of pus at an injection site typically caused by a bacterial infection (Tomolillo et al, 2007). Treatment for an abscess requires antibiotics and a sterile lancing of its contents. If left untreated gangrene can develop and amputation may become necessary. IDUs have been known to attempt to treat abscesses by lancing it themselves. A study in San Francisco that recruited IDUs from homeless shelters or on the street reported that 27% of IDUs have lanced an abscess by themselves and 16% treated their abscess with antibiotics acquired illicitly (Binswanger et al., 2000). IDUs who attempt this put themselves at a significant risk of spreading the infection and furthering the damage. The reason for IDUs attempting to treat abscesses themselves may be because they lack access to a medical professional or because they fear indictment. Known to be of the most stigmatized societal groups in the United States, IDUs are often weary of seeking outside help unless facing immediate danger. An abscess initially causes minor pain and may not seem problematic; IDUs may be ignorant to the severity of the potential complication and choose to not seek immediate help until the infection spreads.

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Cellulitis is an acute inflammation of the dermal and subcutaneous region of the skin caused by a bacterial infection. It manifests as a swollen, red, tender area of skin. If cellulitis is detected early it can be treated with oral antibiotics, but if the infection has spread and causes a fever, treatment requires hospitalization and intravenous antibiotics (Mayo Clinic, 2010).

http://1.bp.blogspot.com/_RCCNZU1r0T0/TO1OCK7oWyI/AAAAAAAAAIc/welKYgMPwVA/s400/upper_abscess1.jpg http://www.kidsgrowth.com/images/fp_images/skin_cellulitis_2.jpg

Figure 3 Cellulitis of the arm Abscess in the forearm

A microbiological assessment of illicit heroin has shown that the most common bacteria found in abscesses are not present in heroin (Tuazon, Hill, & Sheagren, 1974) thereby implying the method of injection as the cause of the infection. This suggests that IDUs who reuse syringes, share syringes, unhygienically prepare their drugs, or have poor personal hygiene have the highest risk of infection. Studies have had mixed results in regard to whether being unhygienic is significantly correlated with contracting a local infection with some finding this relationship to be significant and others not (Binswanger et al., 2000; Vlahov, Sullivan, Astemborski, & Nelson, 1992). The studies that did not find a significant relationship employed a self-report methodology asking IDUs to recall their hygienic practices from up to six months prior.

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Critically assessing these studies leads to the conclusion that answers provided by IDUs may not have been entirely accurate because of the large length of time they were asked to recall and detail. Unhygienic practices are now known to be significantly correlated with local infections (Gagnon & Godin, 2009; Tomolillo et al., 2007). Bacteria on an IDUs skin may enter the users body or latent bacteria on a used syringe may infect a person. Consider the following fictionalized example of two IDUs:
Both Amy and Rachel are IDUs but Amy goes to great lengths to be as hygienic as possible by washing her hands, using sterile syringes, distilled water, disposable cottons and by prepping her injection site with an iodine or alcohol swab prior to injecting. Rachel, however, is ignorant to the compounding risks she partakes in by mixing water from a mug she recently drank from with her heroin prior to injection. She also uses a single syringe for multiple injections and does not have good personal hygiene.

While this is an exaggerated example featuring polarizing users, it articulates the scenario of a condition in which a local infection is most likely to occur. Intravenous drug use is a significant risk factor for endocarditis, a bacterial infection of the inner lining of the heart. After injecting with a contaminated syringe, bacteria can travel through the bloodstream and attach to the interior of the heart. Endocarditis is a serious, potentially fatal medical complication which requires hospitalization. If left untreated, the infection can destroy heart valves which would need to be surgically replaced. Self-reported data amongst IDUs of all drugs show a prevalence rate of endocarditis in 1%-12% of the IDU population of all drugs. The variance is dependent on location, frequency of use, and high-risk practices; IDUs who use often, share syringes, and are unhygienic, are at the highest risk for endocarditis (Phillips & Stein, 2010; Salmon, Dwyer, Jauncey, van Beek, Topp, & Maher, 2009).

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Hepatitis C (HCV) is a virus that is transmitted by sexual or blood-to-blood contact with an infected person. Many complications arise when infected with HCV including cirrhosis, hepatocellular carcinoma, liver disease and death. Of the HCV-infected population, IDUs comprise the largest subgroup. The total prevalence rate of IDUs currently infected with HCV is estimated at 50%, but varies amongst populations and is sometimes as high as 90%. Differences between these populations are due to their location, race, age and gender, with Hispanic IDUs having the highest in the United States (Armstronget al., 2006; Lelutiu-Weinberger et al., 2009). The astoundingly high percentage of IDUs with HCV shows that many IDUs share syringes and do not know how easily transferable the virus is. Needle exchange programs discussed in a later section are specifically designed to address this issue. Human Immunodeficiency Virus (HIV) is the virus that causes Acquired Immune Deficiency Syndrome (AIDS). AIDS is a chronic, life threatening disease that currently has no known cure or vaccine. HIV is transmitted through blood-to-blood contact, sex with an infected person or from mother to child through the placenta or during delivery. HIV damages the bodys immune system by destroying CD4 cells. This leads to the body being unable to fight off diseases and prone to fatal opportunistic infections. A normal CD4 count in the body is between 500 and 1,600 cells per cubic millimeter of blood; once this count falls below 200 cells per cubic millimeter of blood, a person is diagnosed with AIDS (U.S. Department of Health & Human Services, 2010). HIV has an incubation period ranging from several months to several years before progressing into AIDS and some people who are HIV-positive may not have any symptoms of the infection. Within two to four weeks after infection, in the acute stage, clinical symptoms may include fever, chills, rash, fatigue, swollen lymph nodes and ulcers in the mouth. In the latent

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stage of infection that may last up to eight years after the primary infection, HIV reproduces at low levels in the body and may be undetectable. Once a diagnosis of AIDS is made, an infected persons immune system is seriously compromised and vulnerable to opportunistic infections (U.S. Department of Health & Human Services, 2010). While HIV is entirely preventable, due to the practice of sharing syringes and other equipment involved in intravenous drug use, IDUs are a population particularly at risk for acquiring HIV. In the United States, 36% of AIDS cases are comprised by IDUs (CDC, 2002). One in five people currently infected with HIV are undiagnosed, which posits an even greater risk of infection amongst IDUs. The following example articulates how rampantly HIV can spread amongst IDUs:
Five IDUs who live together often share syringes when using drugs. Unbeknownst to them a syringe shared one day had a strain of HIV on it. Now all five individuals are most likely infected. Because of their ignorance in regards to being infected, these five users may go on to share syringes with other users, who may go on to share syringes with even more users, eventually infecting a significant proportion of IDUs in their region.

HIV rates can rise exponentially within a population of IDUs with unsafe practices. Concurrent with the previous example, in the late 1980s at the height of the AIDS epidemic, New York Citys IDU population had an astounding HIV rate of 60% and Asbury Park, New Jersey had a rate of 43% (Chuster, & Pickens, 1988). Infections prevalent amongst IDUs can cause serious, life threatening, chronic conditions. Tragically, these infections primarily arise due to ignorance and a lack of access to syringes. IDUs that practice safe injection procedures such as good personal hygiene, never reusing or sharing a syringe, and swabbing an injection site with alcohol, lower their risk of infection significantly. With proper information and equipment, it is feasible that a user can make their

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likelihood of contracting an infection negligible. Harm reduction programs discussed in later chapters address this issue by educating IDUs and providing them with sterile equipment.

Harm Encountered When One is Physically Dependent


IDUs cannot function normally during physical withdrawal due to their dehabilitating symptoms. Physical withdrawal can last up to 14 days and is described by IDUs as an intense flu or the sickness. Many IDUs are at such a pronounced state of dependence that they use heroin just to feel normal as the recreational aspect of the drug has largely been lost. Similar to a diabetic who requires daily injections of insulin to regulate their disease, IDUs with pronounced physical dependence must use often to avoid becoming violently ill (Mateu-Gelabert et al., 2010). A key aspect to the addictive quality of heroin is the physically dependent user's knowledge of the impending painful withdrawal they will experience if they stop using. This, coupled with the knowledge that their physical and psychological symptoms would disappear immediately upon using, partially explains why IDUs who are physically dependent to heroin have such difficulty quitting. While in physical withdrawal, IDUs are more prone to partake in risky behaviors such as sharing syringes, unsterile injections, seeking drugs in dangerous areas, and seeking partners to use with. This leads to an increased risk of contracting HIV or HCV (Mateu-Gelabert et al., 2010). IDUs become desperate for heroin during physical withdrawal, to the extent that they are willing to undermine their long-term health to satisfy their acute craving. IDUs with a pronounced dependence to heroin suffer dehabilitating withdrawal symptoms. These symptoms can interfere with their cognitive reasoning leading them to partake in risky behaviors and disrupting their ability to function normally. Harm reduction programs

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focusing on physical dependence include maintenance programs and relapse prevention. Maintenance programs supply an IDU with a daily dose of medication which is functionally equivalent to heroin. This sustains an IDU from going through physical withdrawal. Relapse prevention for IDUs who are committed to quitting try to teach IDUs tools to better manage their psychological cravings once their physical withdrawal has ceased. Both of these programs will be discussed in later chapters.

Interpersonal & Intrapersonal Harm Associated with Intravenous Heroin Use


In addition to the harm physically manifested by intravenous heroin use, the IDU population is associated with significant interpersonal and intrapersonal harm. Housing complications, employment and income difficulties, felony indictment and incarceration are correlated with IDUs. These social consequences of drug addiction are explored in this chapter.

Crime, Employment and Income of IDUs


There is a strong relationship between IDUs, unemployment, and crime. As users become increasingly dependent on heroin, they need to earn more money to support their dependence. Long-term employment is rare for IDUs. The high cost of use, coupled with their lack of employment, forces many IDUs to maintain their dependence by illegal means (Alexander & McCaslin, 1974). Maintaining a heroin dependency in addition to a job is very difficult because of the intensely polarizing effects of either being under the influence of heroin or being in withdrawal. While under the influence of heroin, IDUs are profoundly lethargic, and their ability to perform is severely compromised; while in withdrawal however, IDUs are violently ill and often bedridden. These two states largely compose IDUs daily life, and rarely do IDUs feel normal.

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In addition to IDUs inability to maintain a job, acquiring a job may prove troublesome as most employers conduct drug tests prior to employment. Unemployed IDUs earn money through social means like welfare or through illegal means including begging, property crime, theft, and selling heroin. The illegal means by which IDUs earn money makes them a population significantly correlated with misdemeanors, felony convictions, and incarceration. Studies assessing IDUs source of income have determined that 3%-14% is from public welfare programs, 4% from legal employment, 20%-50% from selling heroin or activities involving the heroin trade, and the rest relying on other types of crime (Alexander & McCaslin, 1974). The relationship between IDUs and crime is complicated because knowledge of which act causes the other cannot be determined. Mandatory sentencing for drug convictions is responsible for the large percentage of IDUs currently incarcerated. In a review article about the relationship between socioeconomic status, employment and incarceration amongst the IDU population, Galea and Vlahov, (2002) show remarkable statistics on these variables. Over one-third of inmates in prison are IDUs. Official criminal records show that 46% of inmates incarcerated in federal prisons are there for drug related crimes. This article details why prisons are an especially risky environment for IDUs. Firstly, prisons as a whole are negatively correlated with health status and are considered high-risk environments. Secondly, incarcerated IDUs are still able to access drugs. This fact, coupled with scarcity of syringes in prison, puts incarcerated IDUs who continue to use in prison at great risks for acquiring blood-borne viral infections. In Vancouver, Canada, a study reported that over 54 months, only 28% of IDUs interviewed were ever legally employed while 72% never were. In addition, only 9%-12.5% reported legal employment in the past six months. Variables negatively correlated with

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employment status were being HIV and HCV positive, binge drug use, injecting in public, number of non-fatal overdoses, involvement in the sex trade, and unstable housing (Wood et al., 2010). The negative correlation found between employment and participating in risky behavior may be explained by several theories. Firstly, as acquiring heroin becomes an IDUs main priority, they may relinquish safety precautions that would be benefit their long-term health for an acute craving. Secondly, as being employed requires a person to engage in a routine, IDUs who are employed may not be able to use as frequently as unemployed IDUs; thereby exposing themselves to less risks. Finally, as unemployment and unstable housing is correlated, homelessness may be the mediating variable behind the increased risks associated with unemployment amongst IDUs. This relationship will be discussed in the next chapter. A study in several cities in California that assessed the relationship between crime and IDUs found many significant correlations. Participants in this study were White and Chicano IDUs and the data was procured from their criminal reports in addition to crimes they selfreported in an interview. These IDUs had a mean age of 37 and a mean of 20-24 total arrests in their lifetime. Their mean length of self-reported dependency was between eight and ten years, and their average first official arrest was between 17-18 years of age. The mean length of their career in crime was between 14-17 years and based on their first and most recent arrest. In this sample, IDUs spent an average of three years incarcerated, in treatment, in a halfway house, on probation, or on parole. Self reported membership in gangs was between 36%-67% and largely dependent on race with over two-thirds of Chicanos reporting membership. There was a significant increase amongst the IDUs in crimes committed after they became habitual users.

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IDUs of this population averaged nearly one arrest per year (Deschenes, Anglin, & Speckart, 1991). The data produced by Deschenes et al. (1991) show a strong association between crime and IDUs. Of interest is that the average length in participants career in crime overlaps their average length of time dependent on heroin. This may have been influenced by the large percentage of IDUs in this sample that reported being a member of a gang. Membership in a gang is strongly associated with crime, as a gangs primary purpose is to earn income through illegal means. The overlap between these two variables, however, may be due to other factors. For example, the precise age of when habitual use began may not have been entirely accurate due to the self-report nature of this variable. Because the interview took place prior to placement in a treatment facility, IDUs in this sample may have altered their age of when they began using habitually to appear more responsible and less committed to their dependency in the eyes of the interviewer. There is no objective way to measure the length of their dependence while their criminal history can be verified through official records. It cannot be precisely determined which way the relationship between crime and habitual use goes. What can be concluded, however, is the negative correlation between self-reported periods of employment and crimes committed as well as the negative correlation between self-reported periods of employment and periods of habitual use. These data partially support the notion that IDUs who commit crimes largely do so as a mean to support their dependence. A study in Atlanta, Georgia showed that 3.1% of all violent crime arrests, and 23.4% of property crime and thefts were committed by IDUs in that area. In addition, prior to entering treatment, a sample of IDUs were interviewed. The crimes these IDUs committed a year prior to

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treatment were 50% drug related, 22% property, 2% violent, and 26% other misdemeanors (Alexander & McCaslin, 1974). There is a clear association between IDUs, unemployment and crime. The direct relationship between these three variables is difficult to assess as they each mediate one another. What is known, however, is that a circular type of relationship follows, as IDUs are increasingly dependent on heroin. First, IDUs have a significant dependence to heroin that requires substantial monetary resources to maintain. Second, as they become dependent, it is increasingly difficult to maintain employment or obtain a job. Third, since the illegality of heroin automatically exposes IDUs to an environment conducive for crime, and they desperately need money, they begin to commit crimes such as theft, property damage, or the selling of heroin to support their dependency. Finally, as IDUs have limited monetary recourses, they partake in risky behaviors that will satisfy their acute cravings. This articulation of IDUs descent into crime is not direct and may not be chronological as IDUs may already be committing crimes and participating in risky behaviors prior to being unemployed. Rather, it presents logical explanations for the relationship between unemployment, crime and IDUs. Obtained from Erowid (2006), the following is an actual experience report of an IDU and describes their relationship between dependency, crime, and incarceration:
We did good for a month. We started back just splitting a $30 bag now. We said we wouldn't up our dose, but of course, we did. We ended up pretty bad off for two more years. We ended up breaking into coke machines and asking people on the street for money. I thought I was a good con. People gave me $10, $20, $100. We ended up getting locked up in north Georgia.

Unreliable Housing in IDUs


When one thinks of IDUs, an image of a homeless, malnutritioned, dirty and diseased person may come to mind. And while these may be stereotypical depictions, they do hold some

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merit. In the United States it is estimated that 10%-20% of the current homeless population abuse drugs. Many IDUs end up homeless due to the cost of their drug dependency and housing is a significant determinant of health status (Galea & Vlahov, 2002). These facts present homeless IDUs with compounding risks regarding their health. Corneil et al., (2004) found that only 40% of IDUs in the Vancouver, Canada region had reliable housing. Participants were recruited for an interview at least twice over sevens years, and compensated $20 for each visit. They reported that 60% of the participants were in shelters, recovery or transition homes, jail, or on the street. Unreliable housing was found to be correlated with not being currently enrolled in treatment and sharing syringes. These risky behaviors put IDUs without reliable housing at a significantly elevated risk for HIV transmission. IDUs without reliable housing report higher rates of unsafe sex and lowered rates of seeking and receiving medical care than IDUs with stable housing. This increase in unsafe sex may be caused by unemployment and homelessness leading to sex-trade work as a possible income (Galea & Vlahov, 2002). It is important to note that viruses transmittable when sharing syringes are also transmittable during sex and this puts this population at a tremendous risk of contracting an infection. A study by Sears et al. (2001) examining young homeless IDUs in California found that this population participates in many risky behaviors. The study was done in an interview style, with participants recruited from the street and compensated $20 for their participation. With a mean age of 21, 88% had spent the previous 30 days living in a park or a street and 75% reported being homeless for over two years. Within the past 30 days, over half reported to have shared

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and reused syringes, 37% reused someone elses cotton filter, and over 80% inconsistently cleansed their skin. There is a clear association between being homeless and risky behaviors amongst IDUs. As IDUs devote their entire income to heroin, they cannot afford stable housing. Increasingly risky behaviors including sharing syringes, reusing cotton filters, and injecting under unsterile conditions are prevalent amongst this population and puts these IDUs at an increased risk for blood-borne viruses and bacterial infections. This, coupled with homeless IDUs seeking medical attention at lower rates makes them a population who require urgent attention.

Harm Reduction
Harm reduction is a public health initiative that aims to minimize the harm associated with high-risk behaviors such as injecting heroin. In contrast to traditional approaches such as reducing supply and demand, harm reduction views the IDU population as a public health issue rather than a criminal one. Harm reduction programs such as methadone maintenance, needle exchange programs, and supervised injection sites are discussed in this chapter.

Overview and History of Methadone Maintenance


Methadone used correctly can be a tool for IDUs to stay away from the risky lifestyle associated with IDUs. By regularizing ones dosage with guaranteed access, methadone can dramatically improve an IDUs health. The development of methadone maintenance will be discussed in this chapter in addition to other opiates used as maintenance drugs. Prior to Dole and Nyswanders (1967) groundbreaking clinical trial of methadone being used to treat heroin addiction, IDUs addiction to heroin was thought to be psychogenic in origin, and largely based on character defects and immorality. These alleged character defects made IDUs have sociopathic behaviors, a need to escape reality, and a hedonistic quest for euphoria.

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Sociopathic behaviors associated with heroin use, such as self-centeredness, crime, irresponsibility, and lying, were all assumed to be part of an addictive personality, and present prior to dependency. In addition, IDUs inability to control their drug cravings was seen as evidence of their immorality by virtue of their deficient self-control; moral individuals can abstain from the euphoric temptations of heroin, because they won their struggle of self-control, while IDUs have lost this battle, and thus have a flawed character. Dole and Nyswander presented an alternative theory, classifying heroin addiction as a metabolic disease, where the subsequence behavior of the subject is determined by conditioned reflexes or by metabolic changed in neurons following repeated exposure to narcotic drugs. They theorized that the psychopathology prevalent amongst IDUs was a consequence of their drug hunger, which in turn was caused by a metabolic disorder that was induced by heroin. Methadone is a synthetic opiate that has such a strong affinity to opioid receptors, that it blocks other opiates from binding and exerting their euphoric properties. It has a high oral bioavailability, a long half-life of 24-36 hours, is less intoxicating and less euphoric than heroin, and when provided in adequate dosages, diminishes cravings for opiates, and eliminates opiate withdrawal symptoms (Simon, 1992). While IDUs may use heroin of unknown quality multiple times a day, a controlled dosage of methadone can be prescribed and most often administered once daily. These pharmacological and pharmacokinetical traits made methadone the ideal candidate for Doles and Nyswanders new medical method of treating heroin addiction by IDUs having their physical dependence maintained with methadone. Participants in Dole and Nyswanders (1967) trial were initially hospitalized and given a low dose of 10 to 20mg/day of methadone, which was steadily increased over four to six weeks to a stabilization level of 80 to 120mg/day. Once a participant reached a stabilization level,

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which is marked by the absence of withdrawal symptoms, they can then be maintained in a single, daily, oral ration of methadone, whose dosage remained static. Participants were discharged to an outpatient clinic after six weeks of hospitalization; the clinic dispensed their daily dosage of methadone and collected urine specimens that were analyzed for illicit drugs. Participants were treated psychologically by counseling sessions, socially by being placed in a hospital for six weeks, and biologically with methadone. After six months, over 90% of participants remained in the program, and of these, over 70% reported being employed or attending school. This dramatic improvement on the social standings of participants supported Dole and Nyswanders theory that the psychopathological traits of IDUs are caused by their addiction to heroin. They concluded that if the heroin-seeking behavior of dependent IDUs can be suppressed by methadones narcotic blockade effect, the IDUs social standing and quality of life would greatly improve. After the success of the initial trials of methadone in the mid 1960s, the U.S. congress saw this treatment modality as a possible remedy for the many drug-related crimes that were then plaguing the country (Comer, S.M., & Zacny, J.P. 2005). While in 1968, less than 400 IDUs were enrolled in a methadone maintenance program, by 1973, over 73,000 IDUs reported membership. Between 1971 and 1973 in New York, a marked improvement in drug-related crime was noted, as total robberies, burglaries, and larcenies dropped from 350,000 to 273,000. Nationwide, drug-related death and injury rates dropped significantly during this timeframe. Internationally, during the early 1970s, countries such as Hong Kong, Sweden, and Thailand had results that paralleled the success of the United States. Each of the countries saw a profound improvement regarding criminality and health status amongst IDUs following implementation of methadone maintenance programs because IDUs maintained on methadone are not concerned

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with how they will get their heroin so they can better focus their resources and contribute more to themselves and society than IDUs addicted to heroin. Unfortunately in the mid 1970s, the rapid expansion of these programs in the United States led to less intensive programs in addition to strict regulations by the Food and Drug Administration (FDA). While Dole and Nyswanders original trial in 1967 was intensive, and treated IDUs using a psychobiosocial model, the clinics in the mid 1970s only dispensed methadone and did not provide other types of treatment. The FDA was also concerned with methadone being diverted for sale on the black market and in an attempt to lessen the amount of diverted methadone, limited the time participants can be enrolled in maintenance programs as well as the dosage of methadone they received. Dole and Nyswander opposed many of these mandates as the regulations caused the success and reputation of methadone maintenance programs to suffer. While enrolled, IDUs withdrawal symptoms remained as their dependency was inadequately sustained because of the limitations enacted by the FDA. As a result, many IDUs who were enrolled in a program during this period relapsed on heroin (Comer, S.M., & Zacny, J.P. 2005). Recent studies have supported Dole and Nyswanders theory that methadone exhorts its action by diminishing cravings for heroin and that these cravings are responsible for the psychopathology prevalent amongst IDUs. A meta-analysis of 16 articles conducted by Fareed et al., (2011) analyzed methadones effect on heroin cravings. A majority of the articles reviewed found that methadone reduces heroin cravings. An important finding of this meta-analysis was the strength of the correlation between the dosage of methadone prescribed and subjective cravings reported; as the dosage of methadone increases, subjective reports of heroin cravings decreases. In addition, this meta-analysis outlined trends in the past 30 years in methadone

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dosages. It found that in the 1980s and early 1990s programs typically prescribed daily dosages of 60mg or below. Later, in the mid to late 1990s, the dosages increased and ranged from 60100mg. Finally, in the early 2000s through the present, doses of over 100mg regained prominence and programs tended to mimic the guidelines established by Dole and Nyswander in the mid 1960s. The data in this meta-analysis suggest that doses of 60-100mg is effective in reducing heroin cravings but acknowledges that doses of over 100mg may be necessary in IDUs with a profound tolerance to opiates. A study by Peles et al. (2008) assessed and compared outcome predictors of methadone maintenance programs in Las Vegas, Nevada and Tel-Aviv, Israel. These researchers classified a year-long cessation of opiate use, and a year-long retention in treatment, as the two desired outcomes. In both of the locations, the following variables were associated with longer retention: higher methadone dose, older age, being a parent, no cocaine use, no amphetamine use, no benzodiazepine use. These researchers found that methadone doses of greater than or equal to 100mg/day was the best predictor of retention. After one year, Tel-Aviv patients had retention of 73.6%, while Las Vegas patients had retention of 61.6%. While Dole and Nyswander (1967) had 90% retention in their original trail, the retention rates of this study are considered above average when compared to contemporary clinics across the globe, whose retention ranges were reported to be 38%-65%. In addition, Peles et al. (2008) found that on average, methadone maintenance programs have better retention rates than all other treatment options including therapeutic communities, drug-free outpatient treatment, and chemical dependency treatment. The decline in retention rates after Dole and Nyswanders initial clinical trial can be largely accounted for by the stricter guidelines in regulating and dispensing methadone. Positive Effects of Methadone Maintenance

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As previously illustrated, a significant amount of the harm associated with IDUs is from sharing and reusing syringes. It can be inferred that as an IDU increases their heroin use, their risk for sharing and reusing syringes also increases. Being sustained with methadone, however, eliminates physical and psychological withdrawal symptoms in a single oral dose. It is correlated with a significant decrease in heroin use, and ipso facto, a decrease in the rates of sharing and reusing syringes, HIV, HCV, abbesses, cellulitis, and endocarditis (Bell, & Zador, 2000). Methadone has been shown to reduce rates of crime in IDUs. While IDUs addicted to heroin spend the majority of their time in withdrawal or intoxication, IDUs maintained on methadone inhabit a normal affect comparable to individuals who are not addicted to opiates. In addition, the knowledge that their methadone will always be available removes IDUs from the cycle of earning money illicitly to maintain their heroin addiction. In an assessment on the effectiveness of methadone maintenance treatment across three stats, Ball, Corty, Bond, Myers, & Tommasello. (1998) found a dramatic reduction in criminality in 617 patients. The incidence of many types of crime including shoplifting, parole violation, forgery, weapons offences, burglary, and robbery were measured prior to admission, and at multiple times in treatment over five years. The reduction in criminality was on all types of crime and most reductions were over 80%. Length of Treatment It is important to recognize that while abstinence is a possibility in a program that utilizes a harm reduction philosophy, it may not be the most realistic goal. Long-term methadone maintenance patients, who from a biological standpoint have become physically addicted to methadone, often want to start titrating their dosage until they are free from all narcotics. These patients fail to realize a number of important aspects of methadone maintenance. Firstly,

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methadone is considered a safe drug in long-term use. Secondly, it significantly lessens their psychological cravings for heroin. Finally, even if one utilizes titration and is able to completely detoxify from methadone without any physical withdrawal, their psychological craving for opiates will return shortly and may last for years. There is a poor outlook for IDUs who use methadone to abstain from heroin and then slowly lower their dosage of methadone until they are detoxified from all narcotics. Stimmel, Goldberg, Rotkopf, and Cohen (1977) studied the ability to remain abstinent over a six-year period in 335 patients of a treatment center that sustained and later detoxified its patients with methadone. Treatment in this center was client-based and the length of stay was variable; after detoxification the patient had the choice of either remaining in the programs after-care component or be discharged. In addition, a patient was detoxified and discharged if they violated the rules or were found to have an arrest warrant. Of the 335 detoxified patients, 30% voluntarily discontinued the treatment program, 17% completed treatment, and the rest were either released for arrests or for violating the programs rules. Of the 269 (80%) patients they were able to locate after the six-year observational period, 58% relapsed on heroin, 8% were incarcerated or deceased and only 35% were narcotic-free. These results demonstrate that even after years of abstinence following successful detoxification of methadone, relapse to heroin is quite common. There were several important findings and associations made in this study which support treating IDUs indefinitely (Stimmel et al., 1977). Relapses occurred at all lengths of abstinences, with 35% of relapses occurring after three years. Of the patients who were found to be narcoticfree after six years, 83% completed treatment while 16% detoxified for other reasons. Premature detoxification from methadone was found to be associated with a high recidivism rate. Concurrent with these data, the mean duration of treatment for those who were narcotic-free was

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twice as long as the mean duration of all other groups. It is clear that there is an association between treatment and abstinence and I am in agreement with Stimmell et al., in that it is important not to establish any specific criteria or regulations concerning the length of time that one should receive methadone therapy. Having abstinence as the goal for IDUs who are undergoing methadone maintenance is not realistic and it may even stifle treatment. Gaining admittance to a methadone maintenance program necessitates such a serious addiction to heroin that the metabolic change caused by the severe use could take years for the body to remedy alone. Instead, methadone should be used indefinitely to relieve patients from their physiological withdrawal symptoms in addition to their psychological cravings. The psychological cravings associated with severe heroin addiction will reemerge upon cessation of methadone, even if the physiological symptoms are absent. As Stimmel et al., (1977) illustrated, these psychological cravings can be present for years following abstinence. Abstinence from all opiates including methadone is possible, but because of the high rates of relapse, I would advise programs to only offer the possibility of titrating the dose of methadone to older, established, and employed patients who have been receiving treatment for at least five years. Upon admittance, it would be advisable to inform the patients that this treatment may require adherence over a lifetime. Cost of Treatment The estimated annual cost per patient/client in outpatient methadone maintenance is estimated at $4000-$5200, with inpatient treatment costing far more (McCarty, Frank, & Denmead, 1999; Zaric, Barnett, & Brandeau, 2000). IDUs low socioeconomic status coupled with the high cost of methadone maintenance is a large barrier for those IDUs who seek treatment. Of the money spent on methadone maintenance, it is estimated that 31% is from state

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appropriations, 30% is from federal block grants, 17% is from patient out-of-pocket payments, 12% is from Medicaid, 7% is from local government funds, and 3% is from commercial health insurance. Citing lower rates of HIV amongst methadone maintenance patients in addition to illustrating how the program prevents HIV transmission, it has been argued that providing free methadone maintenance admittance to IDUs is cost-effective, as treatment for HIV costs substantially more than a maintenance program. It is important to note, however, that there is a correlation between ones investment (both fiscally and personally) in any kind of treatment program (e.g. substance abuse, phobic disorders, eating disorders, general psychotherapy) and their success. With this in mind, I would recommend that the cost of admittance to vary relative to the clients economic status, and subsidized by the state or federal government. Side Effects of Methadone While treatment with methadone has a positive impact on the lives of IDUs, as with nearly all drugs that treat chronic conditions, there are side effects. In a review article analyzing methadone maintenance, Bell & Zador (2000) outline several of these side effects in addition to risks of treatment. They found that during the first phase of treatment when the patients dosage is adjusted constantly, there is an increased risk of mortality due to fatal overdose. Possible risk factors for fatal overdose include poor assessment of new clients, hurried increases in dose, and poly-drug intoxication. Regarding side effects, long-term methadone maintenance patients most commonly report lethargy, sedation, decreased motivation, constipation, and sexual problems. In addition, methadone inhibits saliva flow and there is an increased risk of tooth decay in patients. Overall, however, the quality of life of patients drastically improves while they are sustained on methadone, and long-term use does not cause any adverse physiological change. Current Status of Methadone Maintenance in the United States

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Currently, there are three phases for programs in the United States. The first phase is where client's dosages are adjusted until they are properly stabilized. Initially, clients must report to the clinic daily. During the second phase a client's treatment plan is revised and updated. Often this phase has job training and medical and psychological counseling. While the majority of dosages must be taken in front of a nurse, clients in this stage may receive take-home dosages depending on their adherence to the program. This stage of treatment may be extended as long as deemed necessary. The third and final phase of treatment provides ongoing methadone but limits the intensive services provided. Clients as this stage are still required to submit urine samples for drugs and take their dose in front of a nurse. A progressive lowering of methadone with a goal of abstinence may be initiated in this phase. Unfortunately, the current status of methadone maintenance programs in the United States is subpar. Gaining admittance to a methadone maintenance program in the United States is known to be a difficult process. Federal standards require clients to be addicts for over one year and show evidence that they are currently addicted. Most importantly, while the current treatment program is similar to Doles and Nyswanders original trial, it is much less intensive. This fact, coupled with the tight regulation enacted by the FDA has severely limited access and has compromised retention rates. Methadone maintenance needs to be viewed as a long-term intensive psychobiosocial treatment. Not hospitalizing patients leaves them more capable of error. This leads to more evictions for those who do not abide to the program and significantly lowers retention. I would recommend that programs in the United States carefully select clients by outlining long-term treatment goals upon admittance, provide rapid intake of new patients in a hospital setting, offer indefinite stay, subsidize costs to the federal or state government, provide sufficient dosages, and offer counseling services. In addition, programs should be entirely

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directed by the doctors attending to the clients and should not be limited by government regulations. When properly implemented, methadone maintenance programs are successful in reducing crime and health problems associated with IDUs. Critical approaches on methadone maintenance have argued that it is simply replacing one drug with another, and IDUs are not entirely drug-free. It should be noted that many chronic conditions both medical and psychological are treated with a daily dose of a drug and these treatments do not go under the same scrutiny. Why is this so? Successful methadone maintenance programs are attentive to IDUs needs, provide psychological counseling, and administer adequate dosages. By looking at the problems associated with IDUs objectively, and treating it like a condition, the reason they should be treated with methadone is clear. Other Drugs used in Maintenance Therapy Buprenorphine is another drug that has been used in maintenaning opiate dependent IDUs. It has qualities similar to methadone such as negating the effects of other opiates, diminishing cravings for opiates, and eliminating withdrawal symptoms. Clients are stabilized and maintained on a daily dose of buperonorphine that eliminates their withdrawal symptoms and cravings. There are differences between buperonorphine and methadone both pharmacologically and in how they are prescribed. Bupernorhpine has a lower incidence of respiratory depression and is considered safer than methadone. It is less regulated than methadone and an entire month prescription may be given at once. Bupernorphine treatment programs are less intensive than methadone. Often a client will only meet weekly with a psychiatrist for 25 minutes. Studies assessing the effectiveness of bupenorphine in comparison to methadone have had mixed results.

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In one comparison, it was found to be as effective as methadone in reducing illicit opiate use and withdrawal symptoms. However, another study reported that it was less effective in reducing the number of days and money spent on illicit opiates ( Ta p e r t e t a l . , 1 9 9 8 ) . In a comparison with methadone in the detoxification of heroin addicts no significant difference was found (Bicker et al., 1998). Overall, buprenorphine is an effective treatment for heroin addiction only when it is combined with an intensive program that includes counseling and rehabilitating the IDU back into society. Needle Exchange Programs Needle exchange programs (NEPs) are a preventive service that provides IDUs with sterile syringes for little or no cost, or in exchange for used syringes. The philosophy behind NEPs is that with free access to sterile syringes, IDUS will share and reuse syringes less often thereby lessening their exposure to transmittable viruses and bacteria. The development of NEPs are discussed in this section in addition to an assessment of their success at reducing rates of HIV, HVC and local infections, their current status in the United States and recommendations for their future. IDUs in Amsterdam in 1984 started a grassroots movement that led to the first needle exchange program. A trade union was established amongst these users called the Junkiebond that addressed the concerns of hardcore IDUs. These concerns included having an adequate supply of methadone and free access to sterile syringes. This trade union led to the revision in 1985 to the Holland drug policy. Described as a normative approach, the new drug policy viewed IDUs more as an unemployed Dutch citizens than as monsters endangering society. After the revision, many European countries and the United States emulated Hollands approach on

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distributing syringes. Currently in the United States NEPs are legal and present in all 50 states but do not receive any federal funding ( M a r l a t t , 1 9 9 8 ) . A typical NEP offers many services in addition to sterile syringes. To counter the effect of IDUs who are ignorant to their infection status, HIV and HCV tests are regularly given. This information can be vital in reducing instances of syringe sharing. Alcohol swabs are provided to cleanse an injection site and reduce instances of local infections, and distilled water is provided to increase the sterility in injections. Biohazard containers that properly dispose syringes are offered with the goal of reducing the number of used syringes on the street. Finally, many NEPs provide counseling services and can refer IDUs to treatment programs. While the philosophy behind NEPs is noble and the logic is sound, results are mixed in assessing NEPSs influence on the rate of HIV, HCV, and local infections in IDUs. Tomolillo, Crothers, & Aberson (2007) assessed the influence of NEPs on rates of abscesses. Their hypothesis was that NEPs are effective at reducing abscesses in IDUs. Data regarding participant demographics, the number of syringes exchanged, and the number abscesses treated was collected by an interviewer over a two year period. Results showed a significant negative relationship between number of needles exchanged and number of abscesses treated. There was one fewer abscess treated for every 1,000 syringes exchanged. In addition, a significant negative relationship between NEP visits and abscesses treated was found. A simple and objective way of evaluating NEPs is by seeing how many distributed needles are returned. Guydish et al ., (1991) marked syringes with a color coded band at two NEPs in California. They reported that half of the marked syringes distributed were returned within two weeks and 61% were returned in nine weeks. The findings of 50% of syringes were

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returned in two weeks suggest that IDUs exchange used syringes at NEPs repeatedly, and by doing so, reduce their harm. The main purpose of NEPs is to limit the transmission of HIV and HCV, and studies in the past have shown that they are effective at this (Strathdee, & Vlahov, 2001). However, a review of reviews conducted by Palmette et al., (2001) found (a) insufficient evidence to conclude that any of the interventions are effective in preventing HCV transmissions; (b) tentative evidence to support the effectiveness of NEPs in preventing HIV transmission; (c) sufficient evidence to support the effectiveness of NEP in reducing self-reported injecting risk behaviors. Interestingly, while there was evidence to support an association between NEPs and a reduction in self-reported needle sharing, there was no evidence regarding NEPs effectiveness in preventing HCV and HIB transmission. The researchers note that a lack of evidence for NEPs effectiveness in preventing viral infections does not mean that NEPs are not effective. Instead, they outline limitations in the primary studies to explain the discrepancy between these variables. One of the criticisms of the primary studies was that they do not accurately measure how much equipment is distributed in relation to how much was requested. There are strict limits by the FDA on how many syringes can be distributed in NEP. Thus, they concluded that there probably was not an adequate amount of equipment distributed and this led to an increased likelihood of residual syringe sharing amongst IDUs who actively attended NEPs. Another limitation of the primary studies was that the evidence for NEPs effectiveness is based on observational studies; exposure to NEPs was not randomized. A true experiment that measures the differences in HIV and HCV transmission between one group of IDUs with access to NEPs and another with no access, however, would not be ethical. The researchers offer an

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alternative study where one group that has a basic package of NEP services is compared to a group that has an enhanced package of NEP services. The primary studies reliance on self-reported data is yet another limitation. IDUs may have reported engaging in less risky behaviors when is fact they still were. This may explain why IDUs reported lower rates of risky injection practices yet there were no data on biological measures to support this. Seven NEPs in the United States were assessed by Laufer (2001) and all were determined to be cost-effective. The total cost of running these NEPs was $18,224,222. While the majority of funding for NEPs are by the government (both federal and state), 5% of the cost was determined to be donated by volunteers. The number of HIV infections averted was based on an equation with the following parameters: number of unique clients; average rate of HIV in the IDU population; NEP client attendance rate; reduction in HIV incidence. It was estimated that across the seven NEPs, 87 HIV infections were averted and based on the cost of treating HIV over a lifetime, NEPs in this study were found to be a cost-effective and cost-savings strategy for reducing HIV transmissions. In total, it was estimated that the NEPs provides an excess of $20,947 per HIV infection averted. While the goal of NEPs is to reduce the rates of all bloodborne pathogens, this study only assessed the cost-effectiveness of NEPs in reducing HIV infections. If this assessment factored in HCV, abscesses, and cellulitis, the excess would be even more significant. Much of the criticism surrounding NEPs is that in addition to not treating IDUs, they promote a lawless atmosphere which leads to increase rates of drug use and crime. It is important to realize that the goal of NEPs is to lower rates of blood-borne pathogens amongst IDUs who wish to continue using heroin. NEPs are not a form of treatment. They are a public health

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approach that utilizes the harm reduction philosophy. Take for example an IDU who has no plans for abstinence but wants to be safer in their drug use. If that IDU were to go to a conventional public health center, they would be told that their only option is to abstain completely. They would gain nothing in regards to diminishing their risk for blood-borne pathogens. However, if that same IDU were to go to a NEP instead, they would be welcomed with open arms and provided with a variety of services. While there is controversy regarding the effectiveness of NEPs, the claim of increase drug use and crime is unfounded. Marx et al., (2000) studied the trends in crime in Baltimore City after the introduction of a NEP. They found no statically significant rise in drug possession arrests after the establishment of the program in addition to lowered rates of violent offences, break-ins and burglaries. As previously illustrated, there is a relationship between crime as a source of income and drug use. If NEPs increase the rates of drug use, a significant rise in drug possession arrests and economically motivated crimes would be expected. The researchers data did not support this hypothesis of increase drug use following the introduction of a NEP. It can be concluded that the claims of increase crime and drug use are faulty and incorrect.

Supervised Injection Sites


Supervised injection sites (SIS) are medical facilities where IDUs are not prosecuted and can use drugs hygienically under medical supervision. These facilities are similar to NEPs in that they provide IDUs with sterile equipment, HIV and HCV tests, and counseling services. What makes SIS unique is that they are legally sanctioned so IDUs can use drugs in a stress-free environment. In addition, if IDUs were to overdose, they can be treated for immediately. This makes SIS especially useful in reducing harm associated with IDUs. While there are many SIS in

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European countries, the facility in Vancouver, Canada is the first and only one in North America. The impact of this facility on the IDU population in Vancouver is discussed in this section. In September, 2003 InSight was opened in Vancouver, Canada and was granted a 3year constitutional exemption from Canadian drug laws to conduct research (Andrson & Boyd 2010). This facility is considered a type of SIS and is operated by Vancouver Coastal Health which is a publically funded health service. InSight has been able to stay operational because of repeated extensions by the Canadian government. In 2008, the BC Supreme Court granted InSight permanent exemption but this decision was later appealed by the Attorney General. In 2010, the BC Supreme Court rejected the appeal but this was followed up by a further appeal, to the Supreme Court of Canada. This trial is scheduled for May 12th, 2011. The facility in Vancouver, Canada, was assessed by Andrson and Boyd (2010) to determine if it is cost-beneficial and cost-effective. Mathematical models were used to estimate the number of HIV infections and overdoses prevented per year, in addition to public health care cost of a new HIV infection over a lifetime. These models estimated that on average, this facility averts 35 cases of HIV and prevents 3 overdoses each year. These estimates were further analyzed to estimate the economical societal benefit. These data was compared to the known operational cost of $1.5 million per year and estimated that InSight saves over $6 million per year. The cost-effective ratio was found to be 5.12:1. A main criticism of SIS is that they do not treat addiction. In fact, the concept of a SIS may seem outrageous to many. It is important to realize that like NEPs, SIS do not directly treat IDUs and that this does not equate to promoting drug-use and crime. More concrete data on SIS in the coming years will show that SIS effectively reduce the harm associated with IDUs. Consider the example of a heavily addicted IDU who does not currently have a blood-borne

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disease like HIV or HCV but shares syringes and has had non-fatal overdoses. If this IDU was to go to conventional program, it would be expected that they would detoxify and completely abstain from using. Suppose however that this is not possible as this IDU, like the vast majority of IDUs, wants to continue using, albeit safely? A conventional treatment center is useless for this IDU. SIS, however, have much to offer IDUs who want to reduce their risk of both fatal overdose and likelihood of acquiring a blood-borne infection.

Final Thoughts
It is clear that in the United States, the IDU population is viewed both as a public health crisis and as a criminal issue. While IDUs are treated and attended to, they are simultaneously persecuted. The result of this co-existence is programs that attempt to minimize the harm associated with IDUs, but are not effective in doing so. IDUs can be prescribed methadone, but only under strict guidelines and not coinciding with an intensive treatment program. NEPs are available in all 50 states, but only provide a limited amount of syringes. In addition, the looming fear of incarceration is always present and overdoses are a possibility as there are no SIS in the United States. Viewing IDUs as a criminal issue is stifling progression. Progress can only be made when heroin addiction is seen as a metabolic disease, and is treated like any other chronic condition.

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