Talking about drugs.

[This is an excerpt from my only post to a defunct blog from October 17, 2013]

In honor of the Parliament that is not in session in Canada, and the unilateral zipping shut of the Special Access Program, CBC hosted a rogue parliament on The 180.  The panel was convened to discuss whether or not it's a good thing that doctors can no longer prescribe heroin directly to people with heroin addictions who have failed other programs.  The podcast is 12 minutes long and can be viewed here

The panelists were Conservative strategist and blogger Rod Love, National Post columnist Barbara Kay, and journalist Bill Tieleman.  The host, Jim Brown, had a few moments where he brought in clarifying information, but a number of ideas went unchallenged into the ether for our consumption. 

Let's start with some audio from Health Minister Rona Ambrose, which was included in the podcast, “It came to my attention that a group of doctors asked for the ability to use heroin for treatment of addiction.  And there is no evidence at this point that heroin…is in any way an effective treatment."

Hereherehereherehere and here.  And the Mac Daddy from almost 20 years of research on what scientists call heroin-assisted treatment (HAT) is available here.  From the Journal of Urban Health, a 2007 paper that reviewed 10 years of HAT research states, "We conclude this overview with some final observations on a decade of intensive HAT research in the jurisdictions examined, including the suggestion that there is a mounting onus on the realm of politics to translate the—largely positive—data from completed HAT science into corresponding policy and programming in order to expand effective treatment options for the high-risk population of illicit opioid users."

Ambrose continues, "In fact it was my view, and the view of the Prime Minister that this is not a healthy choice and this is not something the Government of Canada supports."

Donuts are also not healthy choices.  As far as I know, they've not been federally banned. Further, the argument Ambrose employs is basically, 'we banned it because we don't like it because we banned it'.  Compelling.  

Heroin as Poison

Then the panel begins, and Barbara Kay starts the discourse by saying that Ambrose's decision "makes a lot of sense" because "Heroin is poison, for heroin addicts."

To be fair, heroin is poison for most people.  Just as the vast majority of medications and pharmaceuticals have the potential to be poisonous.  It's not a reason to not prescribe them.  We continue to give people chemotherapy for cancer, and we use the toxic effects to our advantage to treat the patient.  

And there's more, "and it does not make sense to me, any more sense than it would make to give out alcohol to alcoholics, or any other addicted person something that is making them sicker.  And perpetuating a cycle of decline."  

Just because a policy doesn't make sense to you doesn't mean you're entitled to speak out in the national press without any historical context or literacy in the field.  If you're going to speak about it, learn about it.  As for the cycle of decline, this basically argues that from the first use of heroin, all users embark on a linear downwards trajectory towards despair and abject poverty.  I wonder how Kay would explain 60+ year olds with heroin dependencies, or even people like Cory Monteith who chronically relapse, sometimes getting to abstinence, and sometimes not. 

Speaking of terrible comparisons, Love states, "We don’t have places where alcoholics can go get a bottle of rum,"

They're called liqour stores, in fact.  

And again, "we don’t have places where people who are hooked on prescription drugs can go get prescription drugs,"

They're called doctors.  And, failing that, they're friends, colleagues, family members.     

More from Love, "and I think it’s entirely consistent with the conservative philosophy."

True.  Also, irrelevant because 'conservative' is a political paradigm, not a form of medicine. Also, homeopathy is to medicine what Canada's conservatives are to politics. #noevidence.

At this point, Jim Brown interrupts and says that there are indeed places to get alcohol, if you can't buy it.  And Tieleman adds, "For hard core alcoholics there are places that are supervised, so instead of drinking rot gut or after shave or something, they’re given alcohol."  

More sage input from Love, "you won’t find any of that in Calgary!"  

These programs, known as wet progams, are found in Vancouver, Ottawa, Toronto, and in shelters in most other major cities in Canada, including Calgary.  Second, when folks with obvious alcohol dependencies are brought into hospital for some reasons, to prevent severe withdrawal, pharmacists will often order alcohol, usually peer, as needed every hour or so.  We use alcohol maintenance in Canada in a variety of forms.  Just because you don't know about it, doesn't mean it does not happen.  And yes, it's much easier to deal with than hand sanitizer, antifreeze, hairspray, or mouth wash.   

Ever sensitive, upon finding out that these programs do exist, Kay adds, "You know what, I’d like to sign up for that program, if I were an alcoholic, I would be standing up outside the door participating in this research."  Again, it's not research.  Also, they're usually administered in homeless shelters and hospitals.  Most other people that want to make use of alcohol maintenance can do it themselves because, well, alcohol is legal and widely available in Canada.  Kay and Love have successfully made the distinction between people with alcoholism that live on the street and those that do not.  Seems like they really should be arguing about poverty then, no?  

Ideology as Fact

And then we arrive at the whole wacky discussion of ideology.  

Kay starts, "There are two schools of thought here, the people that believe it’s a disease and it’s akin to giving insulin to diabetic patients..."

Insulin is not psychoactive, and the reason people use psychoactive drugs is because they alter consciousness and, later, because they're dependent and need to prevent withdrawal.  There are some parallels though.  Like addiction, diabetes is a chronic condition, and people do 'relapse' on it as they go through periods where they struggle to stay committed to maintaining their glucose levels.  Diabetes is more prevalent among the very poor, people who smoke and is associated with long term harms.  We do not, however, throw people in jail for failing to manage their glucose, and we make sure that the working poor can afford their medications and test strips.  

She continues, "but we on the other side know that it’s not a disease and it does correlate to availability and social values, and it goes up and down in the population."

This is a rather loaded idea.  Let's break it down. 

Availability: There is no consistent algorithm for the demand and supply of drugs.  Further, it is always hard to assess the actual supply of drugs in any one community at any given time. Suppliers hoard to keep prices high and to ensure supplies last longer, which is what happened after 9/11 in Vancouver and suppliers were worried about port and airport security.  Also, if the drug is not available, then people won't use it.  That's actually half correct. As we've seen with the last year in Canada, where oxycontin has been discontinued, people who abuse pain medications have switched to alternate substances.  They haven't stopped using.  

To be charitable, I think Kay meant to allude to the research of two scientists.  First, Gene Heyman's Addiction: A Disorder of Choice.  I saw Heyman present his research in Ottawa in August 2012, and he presents a variety of compelling arguments that show that if given options, people with addictions will actually behave in economically rational ways.  That is, they can choose to not use, if a better option is available.  The phenomena of addiction remains very complicated, but reductionists like Love and Kay use this basic relationship to argue that we should abandon people who use drugs to their own devices and do basically nothing to help them, other than in-patient treatment centres. Heyman himself is a harm reduction advocate because he realizes that even though the choice between using and not using, in a given moment, is indeed a choice, the ability to exercise that choice from person to person varies.  Say, for example, we're talking about an executive who uses a stimulant to work longer hours with more focus.  If the drug he/she uses starts to interfere with productivity, the choice to use harms his/her bottom line.  In many cases, the executive can moderate their choice to use, just like the vast majority of people who drink alcohol moderate their alcohol use depending on what's on their to-do list the next day.

 If we're talking about someone who has experience post-traumatic stress disorder, has little family, no education, and few other resources, the choice to use IS the rational choice.  It's easier to get through a night in a homeless shelter if you're high, than if you're not.  Further, most homeless shelters won't take people who are drunk or high, so you're most likely going to be sleeping in the street.  For the most vulnerable, and for the most marginalized, using is often the most rational option.  So, one of the reason that heroin-assisted treatment works for the most marginalized is because it acknowledges that the context of use is so marred in poverty, trauma and disenfranchisement, that the user will use 100 percent of the time.  Even if it means jail time, even if it means sex work, even if it means exposure to HIV or Hepatitis C.  The only way to change the parameters of the choice to use is to alleviate the pressure imposed by homelessness, poverty and a lack of opportunity.  The place to start is with helping the user stabilize their life in some respects.  If they're getting prescribed heroin in steady doses at stable, regular times, they can order their day around things like hygiene, learning, eating better, reconnecting with loved ones, and planning for the future.  This is in contrast to ordering their day around stealing, selling tricks and avoiding cops.  The choice to use starts to have more consequences, because life is a bit better, and so maybe they use a little less.  And that's where remission begins.  And that's how the 'addiction is a choice' researchers would be bothered by the far right's adoption of their work as justification of a criminalization focused approach to drug policy.  

The second scientist is Carl Hart, from Colombia University, whose book High Price: A Neuroscientist's Journey of Self-Discovery That Challenges Everything You Know About Drugs and Society, was published this year.  I met Hart in Bangkok in 2009, at the International Harm Reduction Association Conference, the world's foremost conference on alternative approaches to drugs and drug use.  While Heyman uses psychology, genetics and rat experiments, Hart does clinical research with subjects that have pre-existing addictions to 'hard drugs' to show essentially the same thing.  People with addictions are capable of rational economic and social behaviour, but the context of rational choices has to involve a large number of options.  This includes the entire spectrum of harm reduction options for which we have good evidence, such as supervised consumption facilities, voluntary counselling and treatment centres, maintenance and substitution therapies.  It's also important to take away from this that genetics, generational effects and adverse childhood events, like abuse, have immense explanatory power for the rates and distribution of addiction that we see in various communities and regions.  Choices are about opportunities layered over moments, days, years and the life course.  We cannot determine what is rational for someone else without a good long look at the life course. 

Next is, the prickly Social Values:  I suppose Kay intends to say that people who choose to use drugs don't have values because they use instead of spending their time working, or parenting, or whatever.  The vast majority of people who use drugs are not homeless and not unemployed.  So, do they have values?  Is it just the homeless drug users that don't have values?  The street-involved user represents a small percentage of people who use drugs, and this carries even if you exclude marijuana.  The Canadian Centre on Substance Abuse's Canadian Addiction Survey found that "Although about 1 in 6 Canadians has used an illicit drug other than cannabis in their lifetime, few have used these drugs during the past year. Past-year rates are generally 1% or less." There are about 34 million people in Canada, and one percent of that is 340 000.  Kay and Love argue that drug use is about values and is a path to decline, the eventuality of which is, I assume, homelessness.  As of March 2011, there were 28 495 shelter beds in Canada.  So, if one percent of Canadians every year are using a "hard drug", defined as not marijuana, and because using drugs means you have no values and will end up homeless, where are the 310 000 people living on Canada's sidewalks?  That's what I thought.  People end up homeless for a variety of reasons, and people use drugs for a variety of reasons.  Often, it has nothing to do with values, and everything to do with circumstance and opportunity, mental health and trauma.    

Next argument?

Goes up and down in the population:  The argument is that because addiction is a choice, not a disease, prevalence in the population changes when it should...stay the same?.  Rates of influenza in the population also vary year to year.  Is Influenza a choice?  I'm open to the evidence!  The appropriate corollary of the argument is that a steady state prevalence in the population would be evidence that addiction is a 'real' disease, not a choice. Epidemiologists the world round are crying tears of chi's squared.  The prevalence of a disease and the extent to which it is personally determined are unrelated. 

Kay then goes on, "There are some very hard core addicts, but you’re not treating them by allowing them to get their poisons, you’re just allowing them to get high in safer environment with better quality stuff."

Yes.  So?

Lumping it all Together

"There is a lot of ideology behind supervised injection sites,"

Nope.  According to the Supreme Court of Canada, which ruled on Insite, Canada's only supervised injection facility in 2011, "the evidence indicates that a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety".  

Back to Kaye, "and the people that are pushing it are people that do want to legalize hard drugs eventually and treat addiction like a disease just like any other disease.”

As far as I know, the Supreme Court of Canada is not advocating the legalization of hard drugs.  If they did so, I am sure they would have some evidence.  Moving on.

Kaye again, "What we should be doing is looking at rehabilitation, because most addicts can be rehabilitated, even if it’s forced."

Inpatient rehabilitation varies from site to site, but community residential treatment facilities (CRFs) have relapse rates of between 40 and 50 percent.  Lower for the expensive, private places, higher for the public places.  If our gold standard is only 50 percent successful, it's not reliable as a sole option.  If insulin worked 50 percent of the time, we would still be searching for better diabetes treatments and people would still be dying of diabetes itself, as opposed to the complications thereof.  

Next, Kay makes no bones about arguing for forced rehabilitation.  I wonder if Kay knows how much she has in common with China's leaders' approach to drug use.  At least here we don't hold public executions of drug users

From Kaye, "We know that, we have scientific studies showing a very high rate of improvement, and full recovery from addiction, with removing them from the environment."

No, we know the opposite of that.  Also, there are never any beds available in public rehabilitation facilities.  If you want proof, call around to your local municipality, and see what they can do for you. 

"We know that, and it’s a lot cheaper than running these safe injection sites, which lead nowhere."

I am sorry, Supreme Court of Canada, could you speak a little louder? "the evidence indicates that a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety." mmmkay.

As for the cost of inpatient rehabilitation versus supervised injection, are you kidding me?  Supervised injection facilities basically need injection supplies, a building and a nurse.  Rehab centres feed, house and treat people for months at a time.  And they only work 50 percent of the time.  A sterile needle works 100 percent of the time to prevent the spread of infectious diseases.  

And here is the best part, "[Supervised injection facilities] ...simply normalizes drug addiction, and simply sends a non-judgemental message, 'you should not feel bad about the fact that you’re addicted’."  

I suppose Kay is advocating that we should continue the unabashed and untethered public shaming of people who use drugs.  We've been there.  And the problem persists. 

When Tieleman brought up that HAT was only being used for 16 people in British Columbia, Kay stated, "I think that when you introduce these things for only a tiny group of people, it’s the same thing they said with euthanasia, it’s only for a very tiny group of people, and now in Belgium they’re euthanizing 14 year-olds for depression."

To start, euthanasia and HAT are not the same thing, not even close.  Second, you have to be 18 to be eligible for physician-assisted suicide in Belgium.  Third, Belgium is debating legislation now to consider lowering the age to 16, but only for those suffering from "dementia and other 'diseases of the brain'." I presume this means terminal, irreversible diseases of the brain, of which depression is not one of them.  Kay's whole sentence was both illogical and intentionally misleading. 

At some point in the middle of that last argument, Love yells "ya, shoot me up!" and then snickered.  There is no greater evidence that someone doesn't know what they're talking about when they make a very complex and consequential social and medical phenomenon into a punch line during a nationally-broadcasted debate about an actual federal policy.  Nice. 

Love then moseys on to this old trope, directed at Tieleman, "You say that this position of Rona Ambrose is ideology run amok.  Well, yes, it’s an ideological position of a conservative government."

:/

"But your position is also ideological, the left always say it’s ideology run amok but they never confess to the idea that their ideology, opposite though it may be, can also run amok."

True.  But Tieleman did not once brought up the position of Mulcair or Trudeau, and used only actual peer-reviewed, randomized control trial evidence to explain his perspective.  

"We think in this issue, it has....Minister Ambrose said that the science of giving heroin addicts heroin with the view that they will eventually recover, that science is not there

False.  Hereherehereherehere and here

Brown then asked that if the people who use are safer and healthier, isn’t that a positive outcome worth striving for? Love responded with, "They're still stoned, Jim".  

Yes, that is the consequence of addiction.  Thanks.  

Love didn't quit though, moving to "it is inconsistent with the Government of Canada’s anti-drug policy in [Amrose's] opinion.  And she makes the decisions in this respect, not some report from Europe with…"

Ugh.  Europe.  Pinkos.  Eww.  

What were they thinking?

The CBC probably wanted to set up some fit-for-general-public discussion around the Special Access Program and to prod public opinion about heroin assisted treatment for a very small number of heroin users.  And they wanted to do it in a rogue parliament format where politicians discuss matters of great technical detail.  However, the reason the Government of Canada has a civil service machinery is so that it can employ experts to craft scientific approaches, and so that they have something not entirely stupid to say during Question Period, and to Canadians.  

With this episode, The CBC did the national conversation around drug use a great disservice by inviting Kay and Love, both of whom were unprepared, uninformed and very willing to trivialize an issue with which they have no lived experience, and cannot empathize.