SAVING WOMEN'S LIVES -- The Dogwood Center, Princeton, NJ, USA

In 1998, over 40 percent of all women living with AIDS had been infected through injecting drug use.⁽¹⁾ By expanding drug treatment and needle exchange programs, the United States could substantially reduce new HIV infections among women and men who inject drugs.

Drug treatment helps prevent the spread of HIV because people who inject drugs, once in treatment, reduce their drug use and consequently their risk of sharing infected needles. Once in treatment, they also less likely to get involved in risky sex, another way to contract HIV.

A nationally representative survey of 1,800 people in drug treatment, recently published by the U.S. Dept. of Health and Human Services, confirms that treatment helps drug users improve their lives. Comparing the lives of patients 5 years before treatment and 5 years afterward, the study found:⁽²⁾

Of the 23 million Americans who used illicit drugs sometime in 1996, the Office of National Drug Control Policy (ONDCP) estimates that roughly a fifth were in need of drug treatment. Of those thought to be in need of treatment, less than half were actually receiving it.⁽³⁾

The distinction ONDCP makes between drug use and drug dependence (in need of treatment) is a useful one. Once we are able recognize that some people who use drugs are in greater need of treatment than others, we can begin to discuss who should have priority in treatment Because very serious diseases (AIDS and hepatitis B and C) are spread through injecting drug use, it would be reasonable for injecting drug users to be given priority in treatment.

Yet when we turn to the drug most commonly injected - heroin - and its treatment of choice - methadone - we find that access to treatment is very limited.⁽⁴⁾ Only about 154,000 of the estimated 810,000 opiate-dependent persons in the United States are in methadone maintenance therapy.⁽⁵⁾

Some people have opposed methadone maintenance because it involves the use of another opiate, methadone. However methadone does not give a high; it can be legally prescribed; and it is effective. The National Institute of Health Consensus Statement on opiate addiction puts it this way:

Although a drug-free state represents an optimal treatment goal, research has demonstrated that this goal cannot be achieved or sustained by the majority of opiate-dependent people. However, other laudable treatment goals, including decreased illicit drug use, reduced criminal activity, and the attainment of gainful employment can be achieved by most methadone maintenance patients.^{(6), (7)}

Methadone is the only drug treatment option for the opiate-dependent pregnant woman. Methadone combined with sound prenatal care has been shown to decrease obstetrical and fetal complications.⁽⁸⁾ If an opiate-dependent expectant mother undergoes opiate detoxification, her fetus may be harmed or even killed.

Methadone treatment is appropriate only for people dependent on heroin or other opiates.⁽⁹⁾ For individuals who inject cocaine or amphetamines (or other non-opiate drugs), custom treatment strategies or therapeutic communities are appropriate approaches.

The federal government spends 20 percent of the nation's $17 billion drug-control budget to treat drug dependent individuals.⁽¹⁰⁾ Barry R. McCaffrey, Director of the Office of National Drug Control Policy, and experts outside government as well, say it would be both cost effective and humane to increase the government's expenditures on drug treatment.⁽¹¹⁾ Methadone maintenance treatment for heroin addiction costs $3,900 a year; prison about $25,900 a year.⁽¹²⁾

Given the severity of the HIV/AIDS epidemic, the tremendous unmet need for more drug treatment, and the effectiveness of the treatment approaches we now have, the United States should implement the following:

Make methadone maintenance available to all who are dependent on opiates and who wish treatment, including especially pregnant women.⁽¹³⁾ Currently, methadone maintenance therapy is available only to about 1 in 5 heroin users in the United States.

We need to expand substantially the availability of drug treatment for people who inject drugs, both for their own sakes and for the benefits that will come to society from having them out of the drug dependent world. But we also need to be realistic about what to expect from drug treatment as HIV prevention. Not all people who inject drugs are interested in having drug treatment. Drug dependence is a chronic, relapsing disease; this means we must anticipate that some who have gotten treatment will, in fact, relapse.⁽¹⁵⁾ All these considerations lead to a significant conclusion: expanding drug treatment alone cannot stop the spread of HIV among persons who inject drugs. Needle exchange programs are also needed.

(1) Table 25. Centers for Disease Control and Prevention (CDC) HIV/AIDS Surveillance Report. U.S. HIV and AIDS cases reported through June 1999. Midyear Edition.

(2) Page 1. U.S. Dept. of Health and Human Services. Substance Abuse and Mental Health Services Administration. Services Research Outcomes Study. Rockville, MD. September 1998.

(3) The Office of National Drug Control Policy estimates that there were between 4.4 and 5.3 million people in need of drug treatment in 1996. In 1999, when the ONDCP report was written, less than 2 million people receiving drug treatment. Page 59. Office of National Drug Control Policy. National Drug Control Strategy 1999. Washington, D.C. The estimate of the number of the number of persons using illicit drugs in 1996 is taken from page 17, U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, National Household Survey on Drug Abuse: Population Estimates 1996.

(4) New federal rules for methadone maintenance have been proposed that are intended to increase accessibility, quality and oversight of methadone treatment. U.S. Dept. of Health and Human Services. Substance Abuse and Mental Health Services Administration. "New Federal Rules Proposed to Improve Quality and Oversight of Methadone Treatment." Press release. July 22, 1999.

(7) Opiate addiction is a medical disorder with predictable symptoms:
	Despite varying cultural, ethnic and socioeconomic backgrounds, there is a clear consistency in the medial history and symptoms exhibited by individuals who are opiate-dependent.
	There is a strong tendency to relapse after long periods of abstinence.
	The opiate-dependent person's craving for opiates causes continual use even when the dependent person has shown a strong motivation to stop, and there are powerful social consequences for not doing so.
	Continuous exposure to opiates causes changes in the brain.
Page 10. Effective Medical Treatment of Opiate Addiction. National Institute of Health Consensus Statement 1997. November 17-19. Volume 15. No.6. 38 pages.

(9) People who inject a mixture of heroin and cocaine can also be appropriately treated with methadone.

(10) Lauran Neergaard. "Study: Treatment Best for Addicts." Associated Press. March 18, 1999.

(11) Christopher S. Wren. "Top U.S. Drug Official Proposes Shift in Criminal Justice Policy," New York Times, December 9, 1999, p. A23. and George D. Lundberg, "New Winds Blowing for American Drug Policies." Journal of the American Medical Association. September 17, 1999. page 946-7.

(12) David C. Lewis and June E. Osborn, "A Waste of Lives and Money," Washington Post. July 20, 1998, page A17.

(13) In 1993, ten states still had no methadone treatment. Page S226, Ernest Drucker, Peter Lurie, Alex Wodak and Philip Alcabes. 1998. “Measuring harm reduction: the effects of needle exchange and syringe exchange programs and methadone maintenance on the ecology of HIV.” AIDS. Vol. 12 (Supplement A), page S217-S230.