Activists push for heroin help in UN Russia visit

MOSCOW, Feb 10 (Reuters) – Activists have asked the UN human rights

chief to pressure Russia to legalise the heroin substitute methadone when she visits next week amid a worsening HIV/AIDS crisis, an international health group said on Thursday.

UN High Commissioner for Human Rights Navi Pillay will meet President Dmitry Medvedev, government officials and around 60 rights campaigners during a five-day visit to Moscow.

‚This is a national health crisis and a human rights priority in Russia that must be raised at the highest levels,‘ said senior human rights analyst Damon Barrett from the London-based International Harm Reduction Association (IHRA).

The IHRA and 16 other HIV-focused rights organisations have sent a letter to Pillay asking her to push for HIV/AIDS and drug-fighting measures including the introduction of methadone, during her meetings with Russian government.

The UN’s World Health Organisation (WHO) says Russia has one of the fastest growing HIV/AIDS epidemics in the world, fueled up to three million heroin addicts, many of whom use dirty needles, local health organisations say.

Unlike most countries, Russia refuses to finance harm reduction programmes such as needle exchanges, or to legalise the replacement drug methadone.

The Health Ministry says there is no proof methadone is effective, while the country’s top doctor Gennady Onishchenko has called methadone ‚just another narcotic‘.

‚The fact that the government’s policy is so incomprehensible is what makes it so frustrating,‘ Barrett said.

The WHO says there are a million HIV-positive people in Russia, and deems methadone essential in fighting the epidemic.

Pillay will meet Russian activist Irina Teplinskaya during her visit, said the Moscow-based Andrey Rylkov Foundation, for whom Teplinskaya volunteers. HIV-positive and a heroin user, Teplinskaya has become a symbol of Russia’s drug woes.

‚Because there is no opioid substitution therapy in Russia, drug-dependent people are not able to receive treatment for HIV… they are forced to spend whole days acquiring money in a criminal way so they can buy drugs,‘ Teplinskaya said in a speech she will deliver to Pillay on Sunday.

((For a special report on Russia’s heroin and HIV/AIDS problem: ))

Special report: In Russia, a glut of heroin and denial

(Reuters) – In her one-room flat, as a small shelf of porcelain cats looks on and the smell of mold hangs in the air, Zoya pulls down the left shoulder of her black blouse and readies herself for her next hit.

A friend and ex-addict uses a lighter to heat a dark, pebble-like lump of Afghan heroin in a tiny glass jar, mixes it with filtered water and injects it into Zoya’s shoulder. The 44-year-old widow is a wreck: HIV-positive, overweight and diabetic. After 12 years of dealing and drug abuse, the veins in her forearms and feet are covered in bloody scabs and abscesses, too weak and sore to take fresh injections.

Crimson-dyed hair frames her bloated face, which is made up to match a hot pink manicure. As the syrupy brown mixture enters her system, Zoya’s eyes glass over and she ponders her fate and that of her country.

„There are a lot of us. What do they (the government) want to do? Kill us?“ she says. „They want to gather us together and drown us? I worry for tomorrow’s generation.“

If Zoya is anything to go by, today’s Russians are hardly flourishing. Russia has one of the world’s biggest heroin problems, with up to three million addicts according to local non-governmental organizations. Twenty one percent of the 375 tons of heroin produced from Afghanistan’s opium fields now finds its way through central Asia into Russia, according the United Nations. (By contrast, China, with nine times more people, consumes just 13 percent.) The Russian government estimates its citizens bought $17 billion worth of street-traded heroin last year — about seven billion doses. The addiction kills at least 30,000 Russians a year, which is a third of the world’s total heroin-related deaths, adding to pressures on the country’s already shrinking population.

So grave is the problem that President Dmitry Medvedev last year branded heroin a threat to national security.

That’s one reason why last October, 21 years after the end of the decade-long Soviet war in Afghanistan, Russian troops joined forces with U.S. soldiers for a joint drug raid on four Afghan labs. The operation, which destroyed nearly a ton of heroin, was hailed a success and the Cold War foes said they would like to see more such operations in Afghanistan, which is responsible for 90 percent of the world’s heroin production.

At home, though, Russia has been far less active in tackling the problem. Critics go as far as to accuse Moscow of wilfully neglecting its citizens and thereby fuelling what the World Health Organization says is one of the fastest growing HIV/AIDS epidemics in the world.

Unlike most countries around the world, Russia refuses to finance harm reduction programs such as needle exchanges, or to legalize methadone. Over the past few months, Moscow has decided to discontinue the work of foreign donors and NGOs with heroin addicts. It even recently blamed foreign groups for worsening the country’s HIV epidemic.

Health experts and drug addicts alike point to official inaction as the real culprit. It’s as if Moscow has misinterpreted the old U.S. anti-drugs slogan „Just Say No“ and turned its back on the crisis. „My government does nothing for me. I am no longer a person in this society,“ says Zoya, who lives in Tver, a drab city of half a million just off the Moscow-St Petersburg highway, and whose husband, also an addict, died from AIDS several years ago.

Anya Sarang from the Andrey Rylkov Foundation for Health and Social Justice, a small UN-funded Russian organization set up in June 2009, says Russia is failing its people. „For the main groups prone to the disease — drug users, sex workers, migrants — there is absolutely nothing for them,“ says Sarang.

THE PROUD BEAR

Russian officials have a long history of denying crises. From the Soviet government’s refusal to help during the famine of the 1920s to its delay in responding to the 1986 Chernobyl nuclear accident, responses from the top have often mixed disregard and cover-up. During last August’s heat wave, as peat fires and acrid smoke killed hundreds, officials kept silent on the wider health effects of the smoke for weeks.

One of the reasons for the rush to denial lies in the national psyche. Russia is a deeply patriotic country, with a long history of strong governments far removed from the everyday concerns of ordinary citizens. After the humiliating collapse of the Soviet Union 20 years ago and the calamity and poverty that followed, the strongman rule of Vladimir Putin (former president and current Prime Minister) has allowed the Russian bear to flex its muscles on the international stage again.

But while Moscow crows about hosting such high-profile sporting events as the Winter Olympics and soccer World Cup, it ignores daily reality, says health worker Sarang. „Russia is trying to preserve a certain political image, showing that everything is fine,“ she says. „This has shown to be nothing more than a lie.“

Most Russians see the truth all around them. Zoya’s story is repeated so often across the country’s nine time zones that the reality is hard to ignore. Even the government estimates there are 1.8 million heroin users; activists and doctors put the number closer to 3 million, and in a study last June, the United Nations put it at 2.34 million or 1.64 percent of Russia’s population. That’s the world’s third highest heroin abuse rate in per capita terms after Afghanistan and Iran. In absolute numbers, the UN says, Russia is number one.

Heroin was virtually unheard-of during the Soviet era, but is now easy to buy in any city in the country. In Tver, a medium-sized city with relatively little industry and few job prospects for the young, the detritus of addiction — used syringes, needles — litters the streets. Deals are a regular sight on street corners.

Russia’s anti-drugs tsar, Viktor Ivanov, who heads the Federal Drug Control Service — a powerful government body given to U.S.-style rhetoric about the ‚War on Drugs‘– blames the country’s porous Central Asian borders for the heroin hunger.

„Unfortunately, in 1991 we suddenly found ourselves without borders,“ Ivanov told reporters in December, referring to the collapse of the Soviet Union.

Ex-Soviet Tajikistan, which borders Afghanistan and is one of the world’s poorest countries, has long been a haven for drug smuggling out of Afghanistan, where the Tajiks have ethnic ties. From there the heroin flows through Kyrgyzstan and Kazakhstan and into Russia.

INTERTWINED WITH AIDS

The drug problem has now become an AIDS problem. Officially, Russia has 520,000 registered HIV-positive people. The UN and local NGOs say there are probably closer to a million, maybe even more. HIV/AIDS has spread rapidly over the past decade, especially among drug users who regularly share dirty needles. The government estimates around a third of all drug users in Russia are HIV-positive; and international and Russian health experts worry the disease is beginning to spread to the general population through heterosexual sex.

The biggest problem, say health experts, is the government’s refusal to address Russia’s drug addiction. The lack of official intervention is remarkable. There are currently just 70 needle exchange and distribution programs in Russia, reaching a mere 7 percent of heroin addicts according to the London-based International Harm Reduction Association (IHRA). In terms of needle exchanges, „Russia is not even scratching the surface,“ says Rick Lines, executive director of the IHRA.

All the programs are run with foreign funding. Government support: nil. It’s not as if the government is powerless. In the one area of the HIV/AIDS epidemic where it is active — mother-to-child transmission — it has reduced transmission rates to almost zero.

HIGHWAY AIDS TEST

In the face of government inaction, grassroots groups have mushroomed across the country.

Outside Tver, Yuri Suring parks his beat-up black Toyota at a truck stop along the Moscow-Saint Petersburg highway every night. There, between 7 pm and 4 am, he surreptitiously doles out clean needles and condoms to prostitutes, many of whom work to support their drug addictions. „If I were not here, where would these girls go? Who would help them? No one,“ Surin says as a trio of prostitutes in knee-high boots and bomber jackets approaches the car.

Surin’s organization, We And AIDS, consists of himself, a second outreach worker and a driver. The supplies he hands out every night and the kits he uses to test women come, he says, from sympathetic doctors and western groups who want to help.

On a cold night in November, 20-year-old prostitute Olga slips into Surin’s car for an AIDS test. Surin rubs a two-inch indicator on her gums and inserts it into a small plastic tray while Olga nervously smokes a cigarette and shakes her black-bobbed head from side to side in anger at her fate, her gold leaf-shaped earrings swaying.

After studying the result — negative — the prostitute flings the indicator out of the car window and then hops across the gravel into a truck cabin where customers — two large middle-aged truckers — are waiting.

The Health Ministry says it spent 10 billion roubles ($320.5 million) on HIV/AIDS testing and treatment — mostly antiretroviral drugs — in 2010. But activists and health experts say this amount compares badly with other countries in the G20 and sufferers are routinely ignored.

In a 2010 report, the World Health Organization said just a fifth of Russians who needed AIDS drugs were receiving them. South Africa, which has the biggest HIV-positive population in the world — and whose government until recently was criticised as being in denial on AIDS — gives AIDS drugs at almost twice that rate.

„Appeals, trials and public action — nothing works,“ says Alexandra Volgina, head of The Candle Foundation for HIV-positive people, a non-governmental organisationorganization in Saint Petersburg.

When asked why so many sick Russians lack access to AIDS drugs, the health ministry’s spokesman responds: „The amount spent was deemed sufficient.“

POPULATION PROBLEMS

Russians usually blame alcohol for their health problems. Official data shows the average Russian drinks 18 liters (38 pints) of pure alcohol every year, compared with 14 liters in France and eight in the United States.

Official campaigns against drinking have been pursued sporadically since Tsarist times, usually with little success. In September last year Russia banned night-time sales of heavy alcohol, following on from a proposal to double the minimum price of vodka over the next two years in an effort to curb drinking.

„They (the government) are nicer to alcoholics than they are to us,“ says 32-year-old heroin addict and Tver resident Valera, whose scaly hands and face are covered in bright pink scabs from a decade of use. Like many drug addicts, Valera does not work and refuses to say how he funds his $300-a-day habit.

The Geneva-based International Aids Society Aids Society (IAS) warns that if Moscow continues to take no measures, the number of new HIV infections in Russia is likely to grow by 5-10 percent a year, pushing the problem to „an endemic level“, according to IAS president Elly Katabira: the rate will stay constant even without any additional infections from outside the country.

That would hit Russia’s already dwindling population — recently called a „demographic crisis“ by President Medvedev. Heavy smoking, alcoholism, pollution, poverty, low birth rates in the years after the fall of Communism, as well as HIV/AIDS underpin UN projections that the population will shrink to 116 million by 2050 from 142 million now. Moscow — which now gives money to mothers bearing two or more children – targets a population of around 145 million by 2025, but concedes that it could fall to as low as 127 million by 2031.

DESPERATE FOR METHADONE

If one thing appals foreign health officials and activists more than anythappallsing else about Moscow’s response to its heroin problem, it’s the ban on methadone. The WHO regards methadone as essential in combating heroin dependence, but in Russia anyone caught using it or distributing it can face up to 20 years in prison — as harsh a sentence as that for heroin.

Called a replacement drug, methadone is taken by mouth — so reduces the risk of HIV infection by using shared needles — and is used around the world to treat opiate addiction. Russia is one of just three countries in Eastern Europe and Central Asia to ban the drug, alongside Turkmenistan and Uzbekistan, where heroin consumption is relatively low. China, which has over one million registered heroin addicts, with unofficial estimates running several times that, has more than 680 methadone sites.

Methadone is a potent synthetic opiate in its own right, but it can eliminate the agonizing withdrawal symptoms that addicts experience when they quit heroin. Its main advantages are that it has to come from a health-care source, in controlled doses and without needles. That gives addicts some chance, over months or sometimes years, to go clean for good.

In Tver, Yuri Ivanov, a doctor and the deputy head of the state-run Tver Regional Narcology Clinic, is dumbfounded by the ban. „Why do civil servants limit me from doing my work?“ he asks in his dimly lit office in the crumbling grey clinic, which sits off an unpaved muddy lane in the center of the city. „All that they are trying to do is the opposite of what we need. It is hard for me to understand… The situation is going backward. When there is no real medicine, they go right back to drugs.“

Ivanov sometimes resorts to giving his patients tropicamide, a drug used by eye surgeons to dilate the pupils and which has a similar effect to heroin.

Addicts talk of their rare encounters with methadone users with a sense of wonder and even magic. „All of us know about this drug methadone and all of us want it. People come through who have done it and we can instantly see how much brighter and better they live,“ says Tver addict Valera in jittery sentences, high after shooting up twice by midday, in an interview in the back of his tobacco-stained car.

But Moscow won’t be swayed. „The medicine has become more dangerous than the illness. It would be replacing one evil with another,“ said the anti-drugs baron Ivanov. „And why on earth would we do that?“ Gennady Onischenko, the country’s top doctor, repeatedly dismisses methadone as „still a narcotic“.

In a major government anti-drug strategy launched last June, there was no mention of substitution therapy, even though Moscow says it is now focused on reducing the demand for drugs. That means that Russia’s measly four federal and 77 regional rehabilitation centers will continue to treat addicts with psychotherapy, counseling or simple painkillers.

CHAINED TO BED FRAMES

The vacuum created by the lack of effective substitution therapies was highlighted in an incident last October in the Ural Mountains town of Nizhny Tagil. Anti-drugs activist Yegor Bychkov, 23, was sentenced to three and a half years in prison for kidnapping drug addicts. Bychkov said he had received permission from the addicts‘ parents to forcibly take their sons and chain them to steel bed frames while they underwent a painful detox.

Anti-drugs chief Ivanov praised Bychkov, saying he had acted in good will; the head of the parliamentary health committee Olga Borzova said the state was to blame for his arrest as he had become desperate.

The Russian Orthodox Church also weighed in. Though its official stance is against sex education and it regards heroin use as a sin, it has set up its own rehabilitation centers which offer religious guidance. The Church also holds regular discussions with the UN over the HIV/AIDS crisis.

Unfortunately, those sorts of initiatives may be risky. Almost two years ago, the General Prosecutor’s Office was ordered by Russia’s Security Council to beef up prosecutorial measures against non-governmental organizations which advocate substitution therapy. Since then, activists distributing free needles have been detained on charges of aiding illegal drug use.

„Russian government officials consistently promote falsehoods about harm reduction, and deter those who speak in favor of them,“ the IHRA’s Rick Lines says. „Speaking honestly about the vast body of evidence supporting the effectiveness of methadone is a dangerous thing to do (in Russia).“

That may be why relations between the UN’s Global Fund to Fight AIDS, Tuberculosis and Malaria — which has been pushing for methadone legalization — and Russia’s health ministry ruptured at the end of last year. The Global Fund provides the most finance for HIV/AIDS prevention in Russia and granted $351 million to Russia for 2004-11. Now $16 million of that allocation remains, and is at risk of being cut this year.

Worse, say global health experts and local NGOs, is the health ministry’s decision to scrap the Global Fund’s needle distribution, HIV awareness and medication programs. „They proved ineffective and we shall not continue them after 2011,“ said Alexander Vlasov, the ministry’s spokesman.

In October, the health ministry directly accused the Global Fund of making the HIV epidemic worse. „In the regions where these (Global Fund needle) programs were operating, the spread of HIV infection increased three-fold,“ minister Tatyana Golikova told a narcology conference.

The Fund says it is keeping up a dialogue with the Health Ministry. But global health experts warn that the decision to end the Global Fund’s work in Russia will be catastrophic. „Russia will fall behind and lose the achievements made so far,“ warned IAS president Katabira. „We will not be able to recover the situation.“

Antiretroviral Adherence in Methadone!

Very interesting Study,

with a Spanish- English Translation

give it a read: drug-use-and-antiretroviral-adherence-in-EN

Buprenorphine May Boost HIV Treatment

Bridget M. Kuehn

JAMA. 2010;304(3):261-263. doi:10.1001/jama.2010.963

When patients with HIV infection also are addicted to opioids, treating both disorders simultaneously may help improve outcomes and reduce the spread of HIV or other infections transmitted through needle sharing or risky sexual behaviors associated with injection drug use. But accessing such integrated care has sometimes been a challenge for such patients, who generally had to seek care for opioid abuse at addiction treatment centers and primary HIV care elsewhere. This could be logistically difficult and often led to delays in receiving care.

Now, however, buprenorphine prescribing by HIV clinicians is offering patients the option of receiving treatment for both opioid addiction and HIV infection, an approach that a growing body evidence indicates benefits individual patients and public health.

There are currently about 19 000 US physicians certified to prescribe buprenorphine, but experts urge more physicians, particularly those in HIV primary care, to become certified to meet the demand for opioid addiction treatment.

Since 2002, buprenorphine, a partial opioid agonist, has been available in the United States as an office-based treatment for opioid dependence. Physicians who wish to prescribe the drug may under go a training program and become certified through the Substance Abuse and Mental Health Services Administration (SAMHSA) to prescribe buprenorphine (http://buprenorphine.samhsa.gov/). Methadone, a full opioid agonist, remains available through highly regulated, specialized treatment programs.

„Buprenorphine has definitely expanded access [to addiction care],“ said Amina Chaudhry, MD, MPH, an HIV clinician in Baltimore who prescribes buprenorphine. Chaudhry, who is also a medical officer at SAMHSA’s Center for Substance Abuse Treatment in Rockville, Md, explained that even in cities like Baltimore, where there may be specialty addiction programs nearby, the demand for such care often exceeds the available slots. And rural areas may have no specialty addiction programs at all within a reasonable distance.

IMPROVED OUTCOMES

Studies have suggested that patients with HIV infection and untreated opioid addiction often receive HIV treatment later in the course of their illness, may be less adherent to their antiretroviral therapy regimen, and may engage in behaviors such as unprotected sex or injection drug use that put themselves and others at risk of new infections. But treating patients for both HIV and drug use can improve such outcomes. Although much of this research has focused on the effects of methadone, emerging evidence suggests that buprenorphine has similar benefits and may have a few advantages over methadone treatment for patients with HIV.

A recent randomized trial found that office-based care can improve addiction-related outcomes for patients with HIV and opioid addiction and may lead to faster treatment for addiction (Lucas GM et al. Ann Intern Med. 2010;152[11]:704-711). Gregory M. Lucas, MD, PhD, of Johns Hopkins University School of Medicine in Baltimore, and colleagues randomized 93 patients at a Baltimore HIV clinic to receive buprenorphine therapy at the clinic or to receive a referral to specialty addiction treatment elsewhere. Patients randomized to clinic-based opioid agonist treatment with buprenorphine entered addiction treatment much more quickly (84% had initiated such care at 2 weeks compared with 11% in the referral group). During the 12-month trial, participation in opioid addiction treatment was significantly greater in the clinic-based care group (74% participated in such treatment vs only 41% in the referral group). Patients receiving buprenorphine in the clinic also had significantly fewer urine test results that were positive for opioids or cocaine and visited their HIV primary care clinicians more frequently.

However, the researchers did not find differences in HIV-treatment participation or HIV treatment effects between the clinic-based vs referral groups. The authors concluded that the improvements in addiction treatment may have been driven by streamlined access to care because patients referred to outside specialty addiction care may have experienced a delay in treatment initiation. The small sample size may have precluded identifying clinically significant differences in HIV treatment outcomes, they also noted.

The study was part of the Health Resources and Services Administration’s (HRSA’s) Buprenorphine in HIV Primary Care National Evaluation and Support Center (BHIVES; http://www.bhives.org). An analysis of pooled data from 10 sites participating in the HRSA program is under way.

David A. Fiellin, MD, associate professor of medicine at Yale School of Medicine and co-investigator on BHIVES, noted that the program is also probing which approaches to primary care delivery work best in HIV clinics. So far, he and his colleagues have demonstrated in a pilot study that an approach that uses a nurse or other staff member to help coordinate buprenorphine care by overseeing such tasks as urine testing, drug counseling, and medication monitoring can help to reduce drug use among HIV patients, has good retention rates, improves patient function, and promotes patient satisfaction (Sullivan LE et al. Clin Infect Dis. 2006;43[suppl 4]:S184-S190).

Previous studies had suggested that physicians‘ concerns about adherence to antiretroviral treatment by injection drug users with HIV played a role in the likelihood that such patients would be offered highly active antiretroviral therapy or at least experience a delay in receiving such treatment. But results of a French study suggest that integrated treatment of HIV and opioid addiction could allay such concerns. The study found that retention in opioid substitution therapy, either buprenorphine or methadone, is associated with improved virologic outcomes in patients treated with highly active antiretroviral therapy and who had opioid use disorders (Roux P et al. Clin Infect Dis. 2009;49[9]:1433-1440). The study included 53 patients receiving buprenorphine, 28 receiving methadone, and 32 who were not receiving opioid substitution therapy. The median duration of opioid substitution treatment was 25 months.

„Having one-stop shopping for patients means one less barrier to accessing care,“ Chaudhry said.

Buprenorphine also appears to have fewer interactions with antiretroviral drugs than methadone. Elinore F. McCance-Katz, MD, PhD, professor of psychiatry at the University of California, San Francisco, and her colleagues published an article reviewing drug interactions involving methadone and buprenorphine and other medications, including antiretroviral therapies (McCance-Katz EF et al. Am J Addict. 2009;19[1]:4-16). Two HIV medications in particular, efavirenz and nevirapine, have been documented to trigger opiate withdrawal in patients taking methadone but not in patients taking buprenorphine, despite observations of reduced levels of both methadone and buprenorphine when these antiretrovirals were given to patients receiving these opioid therapies, noted McCance-Katz in an interview. A possible reason for the observed differences may be that methadone is metabolized to an inactive substance while buprenorphine is metabolized to norbuprenorphine, which also has opioid effects and may protect patients from experiencing opiate withdrawal, McCance-Katz said.

„It’s very difficult to effectively treat patients [with HIV] if they are in withdrawal,“ she said. „They simply don’t comply with antiretroviral therapy if they are in withdrawal.“

Elevated concentrations of buprenorphine have been documented in patients with opioid dependence and HIV taking atazanavir; such elevated levels were associated with cognitive impairment in a few HIV patients in one case study, while another study in non–HIV-infected patients found only increased drowsiness (Bruce RD and Altice FL. AIDS. 2006;20[5]:783-784 and McCance-Katz EF et al. Drug Alcohol Depend. 2007;91[2-3]:269-278). Such elevations of methadone concentrations have not been documented with atazanavir.

„In general, buprenorphine has fewer interactions with HIV medications, but neither drug has been looked at extensively with many other medications,“ she said, adding that many patients with HIV may be taking a number of medications in addition to antiretroviral drugs.

Integrating buprenorphine treatment into the HIV care setting has another potential advantage: it may be easier for clinicians to spot interactions between addiction and HIV therapies when patients receive buprenorphine treatment at their primary HIV clinic, McCance-Katz said. For example, if a patient receives methadone at one clinic and antiretroviral therapy at another, there may be limited communication between clinicians at the 2 sites and adverse events may not be identified.

CLINICIAN ACCEPTANCE

About 19 000 US physicians are certified to prescribe buprenorphine and about 640 000 patients are receiving the prescriptions compared with about 4500 certified prescribers and a little more than 100 000 patients in 2005, according to Nicholas Reuter, MPH, senior public health analyst at SAMHSA. But access to buprenorphine therapy in the HIV primary care setting in the United States may be limited. Reuter noted that psychiatrists and physicians specializing in addiction treatment were early adopters of office-based buprenorphine prescribing. Today, 31% of the prescribers are classified as general or family practitioners, 21% as psychiatrists, 15% as internal medicine specialists, and the remaining third are other specialists who are not HIV clinicians, according to Reuter. (SAMHSA doesn’t track the number of HIV/AIDS specialists who are certified to prescribe buprenorphine.)

A survey of about 500 HIV clinicians (49.7% response rate) who attended International AIDS Society conferences in the United States in 2006 found that only 85 (17%) worked in offices that prescribe buprenorphine. Of the 323 physicians who responded, only 67 (21%) were certified to prescribe the drug, and only 19 (6%) had ever done so (Kunins HV et al. Fam Med. 2009;41[10]:722-728). Additionally, when presented with a vignette of an opioid-addicted patient with HIV, only 16% of the respondents endorsed primary care buprenorphine treatment as the best option for the patient compared with 49% who endorsed buprenorphine treatment in a substance abuse treatment program and 31% who endorsed methadone treatment in a specialty program.

Fiellin noted that other BHIVES efforts have found that clinicians may feel they do not have adequate training and resources to provide addiction treatment but are interested in receiving additional training. The clinics that have implemented primary care buprenorphine care as part of BHIVES have received technical support during implementation, and over time their satisfaction with and sophistication at providing buprenorphine care have improved, he noted.

Another program offering resources to buprenorphine-prescribing physicians is SAMHSA’s Physician Clinical Support System (PCSS), which is directed by Fiellin and includes McCance-Katz as among the clinical experts who work with the program. PCSS helps match new buprenorphine prescribers to more experienced mentors who work in similar settings, including HIV primary care. The program also has drafted a guidance document for buprenorphine prescribing to patients with HIV (http://www.pcssbuprenorphine.org/pcss/documents2/PCSS_OpioidTherapiesHIVDrugInteractions_022808.pdf).

SAMHSA is also working with primary care physicians at federally qualified health centers who may be treating many HIV-infected patients. Reuter explained that the agency would like these centers to offer both buprenorphine and methadone, although the latter would require a center to be licensed as an opioid treatment clinic. He noted that SAMHSA’s goal is to make sure there are as many physicians as possible qualified to provide care to opioid-dependent patients, who may require long-term or recurrent care. For example, the average duration of methadone treatment is 6.8 years. „Our concern is that as long as patients remain engaged in treatment they do very well,“ he said. „A number of patients discontinue and the relapse rate is very high.“

Chaudhry emphasized that primary care buprenorphine treatment is not necessarily a replacement for specialty addiction treatment with methadone or buprenorphine. For example, she noted that some patients may prefer to keep their addiction treatment separate from their HIV care.

„The more treatment choices that providers have to offer the better,“ she said.

A Role for Buprenorphine in Prevention?Between 2004 and 2007, of the 152 917 US individuals in 34 states diagnosed with new HIV infections, 13% of them (n = 19 687) were injection drug users, according to the US Centers for Disease Control and Prevention (MMWR Morb Mortal Wkly Rep. 2009;58[46]:1291-1295). For those who are already infected with HIV, buprenorphine treatment may reduce the likelihood they will spread the infection to others through needle sharing or unprotected sexual activity. And for opioid-dependant individuals who are not already HIV-infected, primary care buprenorphine treatment may reduce risky behaviors that put them at risk of HIV infection, according to a recent study. Lynn E. Sullivan, MD, and colleagues from the Yale University School of Medicine in New Haven, Conn, compared drug-related and sex-related risk behaviors in 166 buprenorphine-treated individuals at baseline, 12 weeks, and 24 weeks (Sullivan LE et al. J Subst Abuse Treat. 2008;35[1]:87-92). Reports of intravenous drug use among the individuals declined over time, from 37% at baseline to 12% at 12 weeks, to 7% at 24 weeks. The researchers also found a decline in reports of sex while the patient or their partner was high between baseline (64%) and 12 weeks (13%), although such reports increased to 15% a 24 weeks, and inconsistent condom use with a regular partner remained unchanged. Such benefits may be particularly important in regions of the world where HIV transmission is driven primarily by injection drug use. In Eastern Europe and Central Asia, for example, the Joint United Nations Programme on HIV/AIDS estimates that more than 80% of all HIV infections are caused by contaminated injection equipment (http://www.unaids.org/en/PolicyAndPractice/KeyPopulations/InjectDrugUsers/). The HIV Prevention Trials Network, an international clinical trials network funded by the National Institute of Allergy and Infectious Diseases, currently has a phase 3 randomized trial under way in China and Thailand to assess whether buprenorphine in combination with naloxone (to reduce the abuse potential) decreases drug use and HIV-related risk behaviors (http://www.hptn.org/research_studies/HPTN058.asp). The trial, which is enrolling about 1500 HIV-uninfected injection drug users, will randomize individuals to receive either buprenorphine plus naloxone for 1 year or detoxification with buprenorphine plus naloxone for up to 18 days (with a second detoxification if necessary). Both groups will also receive counseling for HIV risk reduction. The study will assess cumulative HIV incidence and death and frequency of drug use and drug-related and HIV-related risk behaviors in the 2 groups.—B.M.K.

The Vienna Declaration, be active!

I had it already a few days ago but it is important for every one,

make this Viral (WWW)

Please sign the declaration here.

Between now and 2012 it’s up to you and your friends, communities, governments, newspapers, to advocate for evidence based drug policy and strengthen the call for policies driven by evidence. Join the movement to end the failed war on drugs, sign the declaration and share it with your networks today.

The Vienna Declaration is a statement seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies. We are inviting scientists, health practitioners and the public to endorse this document in order to bring these issues to the attention of governments and international agencies, and to illustrate that drug policy reform is a matter of urgent international significance. We also welcome organizational endorsements.

The declaration process was launched as the the official declaration of the XVIII International AIDS Conference (AIDS 2010) held in Vienna, Austria from July 18th to 23rd. The declaration was drafted by a team of international experts and initiated by several of the world’s leading HIV and drug policy scientific bodies: the International AIDS Society, the International Centre for Science in Drug Policy (ICSDP), and the BC Centre for Excellence in HIV/AIDS.

Backgrounder

What the Vienna Declaration Is

Why We Need It

Policy Today: A Proven Failure

The Need for Change

Lending Your Name

What Else You Can Do

1. What the Vienna Declaration Is

The Vienna Declaration is a statement seeking to improve community health and safety by calling for the incorporation of scientific evidence into illicit drug policies. The declaration is the official declaration of the XVIII International AIDS Conference (AIDS 2010) to be held in Vienna, Austria from July 18th to 23rd, 2010. The declaration was drafted by a team of international experts and initiated by several of the world’s leading HIV and drug policy scientific bodies: International AIDS Society, the BC Centre for Excellence in HIV/AIDS, and the International Centre for Science in Drug Policy (ICSDP). It was prepared through an extensive consultative process involving global leaders in medicine, public policy and public health.

2. Why We Need It

The world needs a new approach to dealing with illicit drugs. The primary international response to the health and social harms posed by drug use has involved a global “war on drugs” aimed at reducing the availability and use of illegal drugs through drug law enforcement.

3. Policy Today: A Proven Failure

In June 1998, the UN General Assembly hosted a Special Session on illegal drugs under the slogan “A drug free world – We can do it.” The session set out international drug control strategies and law enforcement goals for the subsequent decade in which it was hoped the world could be made “drug free.”

However, it is now clear that drug law enforcement has not achieved its stated objectives. In fact, illicit drugs remain readily available worldwide, and the previous three decades have seen drug prices continue to fall while drug purity continues to increase. In addition, the over-reliance on drug law enforcement has resulted in overwhelmingly negative health and social consequences. This includes the enrichment of organized crime and associated violence, the spread of HIV among injection drug users, as well as other devastating harms as outlined in the Vienna Declaration.

The negative effects of drug control efforts in the United States led to a unanimous resolution at the 2007 annual United States Conference of Mayors that stated that the War on Drugs has failed. The resolution called for a “New Bottom Line” in drug policy, and demanded a public health approach focused on reducing the negative consequences associated with drug abuse while ensuring that policies do not exacerbate problems or create new social problems of their own.

4. The Need for Change

The need for evidence-based public health approaches is clear, yet drug law enforcement continues to be the dominant policy approach at the expense of all others, including public health interventions that have been proven effective. For instance, methadone maintenance therapy remains illegal in Russia and other parts of the world where HIV is spreading most rapidly among heroin users. This ban persists despite the fact that methadone is on the World Health Organization’s list of Essential Medicines and is recognized as one of the most effective treatments for heroin addiction.

The status quo cannot be tolerated any longer: illicit drug policy must be based on scientific evidence to protect and improve the health and well-being of individuals and communities around the world.

5. Lending Your Name

By signing the Vienna Declaration, you will be adding your name to those who have already called for the implementation of evidence-based policies that can meaningfully improve community health and safety by reducing the toll of drugs globally.

6. What Else You Can Do

To spread the word and support the organizations bringing forward this important work, click here. If you are a scientist, academic or health practitioner holding a PhD or MD who would like to continue to speak out about the need for evidence-based drug policy, please click here.

The Vienna Declaration

The criminalisation of illicit drug users is fuelling the HIV epidemic and has resulted in
overwhelmingly negative health and social consequences. A full policy reorientation is needed.

In response to the health and social harms of illegal drugs, a large international drug prohibition regime has been developed under the umbrella of the United Nations.1 Decades of research provide a comprehensive assessment of the impacts of the global “War on Drugs” and, as thousands of individuals gather in Vienna at the XVIII International AIDS Conference, the international scientific community calls for an acknowledgement of the limits and harms of drug prohibition, and for drug policy reform to remove barriers to effective HIV prevention, treatment and care.

The evidence that law enforcement has failed to prevent the availability of illegal drugs, in communities where there is demand, is now unambiguous.2, 3Over the last several decades, national and international drug surveillance systems have demonstrated a general pattern of falling drug prices and increasing drug purity—despite massive investments in drug law enforcement.3,4

Furthermore, there is no evidence that increasing the ferocity of law enforcement meaningfully reduces the prevalence of drug use.5 The data also clearly demonstrate that the number of countries in which people inject illegal drugs is growing, with women and children becoming increasingly affected.6 Outside of sub-Saharan Africa, injection drug use accounts for approximately one in three new cases of HIV.7, 8 In some areas where HIV is spreading most rapidly, such as Eastern Europe and Central Asia, HIV prevalence can be as high as 70% among people who inject drugs, and in some areas more than 80% of all HIV cases are among this group.8

In the context of overwhelming evidence that drug law enforcement has failed to achieve its stated objectives, it is important that its harmful consequences be acknowledged and addressed. These consequences include but are not limited to:

HIV epidemics fuelled by the criminalisation of people who use illicit drugs and by prohibitions on the provision of sterile needles and opioid substitution treatment.9, 10
HIV outbreaks among incarcerated and institutionalised drug users as a result of punitive laws and policies and a lack of HIV prevention services in these settings.11-13
The undermining of public health systems when law enforcement drives drug users away from prevention and care services and into environments where the risk of infectious disease transmission (e.g., HIV, hepatitis C & B, and tuberculosis) and other harms is increased.14-16
A crisis in criminal justice systems as a result of record incarceration rates in a number of nations.17, 18 This has negatively affected the social functioning of entire communities. While racial disparities in incarceration rates for drug offences are evident in countries all over the world, the impact has been particularly severe in the US, where approximately one in nine African-American males in the age group 20 to 34 is incarcerated on any given day, primarily as a result of drug law enforcement.19
Stigma towards people who use illicit drugs, which reinforces the political popularity of criminalising drug users and undermines HIV prevention and other health promotion efforts.20, 21
Severe human rights violations, including torture, forced labour, inhuman and degrading treatment, and execution of drug offenders in a number of countries.22, 23
A massive illicit market worth an estimated annual value of US$320 billion.4 These profits remain entirely outside the control of government. They fuel crime, violence and corruption in countless urban communities and have destabilised entire countries, such as Colombia, Mexico and Afghanistan.4
Billions of tax dollars wasted on a “War on Drugs” approach to drug control that does not achieve its stated objectives and, instead, directly or indirectly contributes to the above harms.24

Unfortunately, evidence of the failure of drug prohibition to achieve its stated goals, as well as the severe negative consequences of these policies, is often denied by those with vested interests in maintaining the status quo.25This has created confusion among the public and has cost countless lives. Governments and international organisations have ethical and legal obligations to respond to this crisis and must seek to enact alternative evidence-based strategies that can effectively reduce the harms of drugs without creating harms of their own. We, the undersigned, call on governments and international organisations, including the United Nations, to:

Undertake a transparent review of the effectiveness of current drug policies.
Implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use.
Decriminalise drug users, scale up evidence-based drug dependence treatment options and abolish ineffective compulsory drug treatment centres that violate the Universal Declaration of Human Rights.26
Unequivocally endorse and scale up funding for the implementation of the comprehensive package of HIV interventions spelled out in the WHO, UNODC and UNAIDS Target Setting Guide.27
Meaningfully involve members of the affected community in developing, monitoring and implementing services and policies that affect their lives.

We further call upon the UN Secretary-General, Ban Ki-moon, to urgently implement measures to ensure that the United Nations system—including the International Narcotics Control Board—speaks with one voice to support the decriminalisation of drug users and the implementation of evidence-based approaches to drug control.28

Basing drug policies on scientific evidence will not eliminate drug use or the problems stemming from drug injecting. However, reorienting drug policies towards evidence-based approaches that respect, protect and fulfil human rights has the potential to reduce harms deriving from current policies and would allow for the redirection of the vast financial resources towards where they are needed most: implementing and evaluating evidence-based prevention, regulatory, treatment and harm reduction interventions.

REFERENCES
1. William B McAllister. Drug diplomacy in the twentieth century: an international history. Routledge, New York, 2000.
2. Reuter P. Ten years after the United Nations General Assembly Special Session (UNGASS): assessing drug problems, policies and reform proposals. Addiction 2009;104:510-7.
3.United States Office of National Drug Control Policy. The Price and Purity of Illicit Drugs: 1981 through the Second Quarter of 2003. Executive Office of the President; Washington, DC, 2004.
4. World Drug Report 2005. Vienna: United Nations Office on Drugs and Crime; 2005.
5. Degenhardt L, Chiu W-T, Sampson N, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine use: Findings from the WHO World Mental Health Surveys. PLOS Medicine 2008;5:1053-67.
6. Mathers BM, Degenhardt L, Phillips B, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: A systematic review. Lancet 2008;372:1733-45.
7. Wolfe D, Malinowska-Sempruch K. Illicit drug policies and the global HIV epidemic: Effects of UN and national government approaches. New York: Open Society Institute; 2004.
8. 2008 Report on the global AIDS epidemic. The Joint United Nations Programme on HIV/AIDS; Geneva, 2008.
9. Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange programme in the USA. Lancet 1997;349:604.
10. Rhodes T, Lowndes C, Judd A, et al. Explosive spread and high prevalence of HIV infection among injecting drug users in Togliatti City, Russia. AIDS 2002;16:F25.
11. Taylor A, Goldberg D, Emslie J, et al. Outbreak of HIV infection in a Scottish prison. British Medical Journal 1995;310:289.
12. Sarang A, Rhodes T, Platt L, et al. Drug injecting and syringe use in the HIV risk environment of Russian penitentiary institutions: qualitative study. Addiction 2006;101:1787.
13. Jurgens R, Ball A, Verster A. Interventions to reduce HIV transmission related to injecting drug use in prison. Lancet Infectious Disease 2009;9:57-66.
14. Davis C, Burris S, Metzger D, Becher J, Lynch K. Effects of an intensive street-level police intervention on syringe exchange program utilization: Philadelphia, Pennsylvania. American Journal of Public Health 2005;95:233.
15. Bluthenthal RN, Kral AH, Lorvick J, Watters JK. Impact of law enforcement on syringe exchange programs: A look at Oakland and San Francisco. Medical Anthropology 1997;18:61.
16. Rhodes T, Mikhailova L, Sarang A, et al. Situational factors influencing drug injecting, risk reduction and syringe exchange in Togliatti City, Russian Federation: a qualitative study of micro risk environment. Social Science & Medicine 2003;57:39.
17. Fellner J, Vinck P. Targeting blacks: Drug law enforcement and race in the United States. New York: Human Rights Watch; 2008.
18. Drucker E. Population impact under New York’s Rockefeller drug laws: An analysis of life years lost. Journal of Urban Health 2002;79:434-44.
19. Warren J, Gelb A, Horowitz J, Riordan J. One in 100: Behind bars in America 2008. The Pew Center on the States Washington, DC: The Pew Charitable Trusts 2008.
20. Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Social Science & Medicine 2005;61:1026.
21. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug and Alcohol Dependence 2007;88:188.
22. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global drug control policy. Canadian Medical Association Journal 2005;172:655-6.
23. Edwards G, Babor T, Darke S, et al. Drug trafficking: time to abolish the death penalty. Addiction 2009;104:3.
24. The National Centre on Addiction and Substance Abuse at Columbia University (2001). Shoveling up: The impact of substance abuse on State budgets.
25. Wood E, Montaner JS, Kerr T. Illicit drug addiction, infectious disease spread, and the need for an evidence-based response. Lancet Infectious Diseases 2008;8:142-3.
26. Klag S, O’Callaghan F, Creed P. The use of legal coercion in the treatment of substance abusers: An overview and critical analysis of thirty years of research. Substance Use & Misuse 2005;40:1777.
27. WHO, UNODC, UNAIDS 2009. Technical Guide for countries to set targets for universal access to HIV prevention, treatment and care for injection drug users.
28. Wood E, Kerr T. Could a United Nations organisation lead to a worsening of drug-related harms? Drug and Alcohol Review 2010;29:99-100.

Vienna Declaration Writing Committee

For comments and insights from members of the Vienna Declaration writing committee and other signatories click here.

Evan Wood, MD, PhD (Chair)
Director, Urban Health Research Initiative
Associate Professor, University of British Columbia
Canada

Frederick L. Altice, MD
Professor of Medicine & Director of Clinical and Community Research
Yale University School of Medicine
USA

Dennis Altman AM, FASSA, MA
Professor of Politics, La Trobe University
Director, Institute for Human Security
Australia

Judith D. Auerbach, PhD
Vice President, Science & Public Policy
San Francisco AIDS Foundation
USA

Anurita Bains
Senior Advisor, Office of the Executive Director
The Global Fund to Fight AIDS, TB and Malaria
Switzerland

Prof. Françoise Barré-Sinoussi, PhD
Nobel Laureate
Professor and Head, Unit of Regulation of Retroviral Infections, Department of Virology
Institut Pasteur, Paris

Damon Barrett
Senior Human Rights Analyst, International Harm Reduction Association
Australia

Jacqueline Bataringaya, MD, MA
Senior Policy Adviser

, International AIDS Society
Switzerland

Chris Beyrer, MD
Professor, Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
USA

Maria Patrizia Carrieri, PhD
Researcher, Institut National de la Santé et de la Recherche Médicale
France

Grant Colfax, MD
Director of HIV Prevention and Research
San Francisco Department of Public Health
USA

Marcus Day, DSc
Director, Caribbean Drug & Alcohol Research Institute
Saint Lucia

Don C. Des Jarlais, PhD
Professor of Epidemiology
Director of the International Research Core Center for Drug Use and HIV Research
USA

Françoise Girard
Director, Public Health Program, Open Society Institute
USA

Robin Gorna
Executive Director, International AIDS Society
Switzerland

Carl L Hart, PhD
Associate Professor of Psychology
Departments of Psychology and Psychiatry, Columbia University
USA

Ralf Jürgens, PhD
Consultant, HIV/AIDS, Health, Policy and Human Rights
Canada

Adeeba Kamarulzaman, MD
Head of Infectious Disease Unit, University of Malaya Medical Centre
Malaysia

Michel D. Kazatchkine, MD
Executive Director, The Global Fund to Fight AIDS, TB and Malaria
Switzerland

Thomas Kerr, PhD
Director, Urban Health Research Initiative
Associate Professor, University of British Columbia
Canada

Danny Kushlick
Head of Policy, Transform Drug Policy Foundation
England

Rick Lines
Deputy Director, International Harm Reduction Association
Australia

Barbara McGovern, MD
Associate Professor of Medicine, Tufts University School of Medicine
USA

Julio S.G. Montaner, MD, FRCPC, FCCP, FACP, FRSC
Professor, Chair in AIDS Research and Head of Division of AIDS, University of British Columbia
President, International AIDS Society
Canada

David Nutt, MD, FRCP, FRCPsych, FMedSci
Director, Neuropsychopharmacology Unit, Division of Experimental Medicine
Hammersmith Hospital, Imperial College of London
England

Thomas L. Patterson, PhD
Professor of Psychiatry, University of California, San Diego
USA

Tim Rhodes, PhD
Professor and Director, Centre for Research on Drugs and Health Behaviour
London School of Hygiene and Tropical Medicine
England

Brigitte Schmied, MD
President, Austrian AIDS Society, AIDS 2010 Local Co-Chair
Head of HIV Outpatient Clinic, Otto-Wagner-Spital Vienna
Austria

Steffanie Strathdee, PhD
Harold Simon Professor and Chief, Division of Global Public Health, Department of Medicine
University of California, San Diego School of Medicine
USA

Sharon Walmsley, MD, MSc, FRCPC
Professor, Department of Medicine, University of Toronto, Division of Infectious Diseases
Canada

Dan Werb, MSc
Research Associate, BC Centre for Excellence in HIV/AIDS
Canada

Alexander Wodak, FRACP, FAChAM, FAFPHM, MBBS
Director, Alcohol and Drug Service, St. Vincent’s Hospital
Australia

Expertise zur Heroinverschreibung

INHALTSVERZEICHNIS
PRÄAMBEL _____________________________________________________________________________ 6
1. Die Substanz Diazetylmorphin______________________________________________________________ 8
1.1. Pharmakologie_______________________________________________________________________ 8
1.2. Medizinische Verwendung _____________________________________________________________ 8
1.3. Pharmakokinetik _____________________________________________________________________ 8
1.4. Wirkungen und Nebenwirkungen von Diacetylmorphin ______________________________________ 10
1.4.1. Wirkungen ______________________________________________________________________ 10
1.4.2. Nebenwirkungen / Unerwünschte Wirkungen___________________________________________ 10
1.4.3. Interaktionen ____________________________________________________________________ 11
1.4.4. Intoxikation _____________________________________________________________________ 11
1.4.5. Entzugssymptomatik ______________________________________________________________ 11
1.4.6. Anwendungseinschränkungen und Vorsichtsmaßnahmen – EXKURS: Heroin und
Verkehrstüchtigkeit ________________________________________________________________ 11
1.5. DAM-Zubereitungen und Einnahmeformen _______________________________________________ 12
1.6. Heroinabhängigkeit __________________________________________________________________ 15
2. EXKURS über Heroinmythologie und Heroinkontrolle _________________________________________ 16
2.1. Der Mechanismus der Drogenkontrolle – Die Entwicklung der Internationalen Kontrolle der Narkotika 16
2.2. Der historische Hintergrund der Heroinkontrolle ___________________________________________ 16
2.3. Heroin als Problemdroge ______________________________________________________________ 16
2.4. Die Heroinmythologie ________________________________________________________________ 18
2.4.1. Die Ebenen der Dämonisierung des Heroins in den USA __________________________________ 18
2.4.2. Heroin in Europa _________________________________________________________________ 21
2.4.3. Ergebnisse der Literaturanalyse 1920-1945_____________________________________________ 22
2.4.3.1. Außermedizinische Literaturquellen _______________________________________________ 23
2.4.3.1.1. Heroin in Frankreich ________________________________________________________ 24
2.4.3.1.2. Heroin und Okkultismus _____________________________________________________ 25
2.5. Kontrolle und Mythologie 1923-1931 ____________________________________________________ 25
2.6. Die Auswirkungen der amerikanischen Heroinmythologie auf die europäische Einstellung in der
Zwischenkriegszeit __________________________________________________________________ 26
2.7. Die Situation nach dem Zweiten Weltkrieg________________________________________________ 27
3. Heroin in der Behandlung der Heroinabhängigkeit _____________________________________________ 28
3.1. Überblick über grundsätzliche Positionierungen in den verschiedenen Heroinstudien _______________ 29
3.1.1. Das Ungenügen der Methadonsubstitution _____________________________________________ 29
3.1.2. Ärztliche Heroinverschreibung als schadensbegrenzende Maßnahme ________________________ 30
3.1.3. Die Kontroverse um die Heroinverschreibung __________________________________________ 32
4. Heroinprojekte international_______________________________________________________________ 33
4.1. SCHWEIZ _________________________________________________________________________ 33
4.1.1. Entwicklung und rechtliche Grundlage der HeGeBe______________________________________ 33
4.1.1.1. Die legistischen Rahmenbedingungen______________________________________________ 34
3
4.1.1.1.1. Drogenpolitik als Aufgabe des öffentlichen Gesundheitswesens ______________________ 34
4.1.1.1.2. Die katalysatorische Wirkung von AIDS ________________________________________ 35
4.1.2. Überprüfbare Zielsetzungen der schweizerischen Drogenpolitik seit 1991_____________________ 37
4.1.3. Die Schweizer Studie zur medizinischen Opiatvergabe (PROVE) ___________________________ 38
4.1.3.1. Supervisionsorgane, Expertengremien und Begleitgruppen _____________________________ 40
4.1.3.2. Praktische Umsetzung __________________________________________________________ 41
4.1.3.3. Begleitforschung ______________________________________________________________ 43
4.1.3.3.1. Substanzforschung _________________________________________________________ 43
4.1.3.3.2. Medizinische Forschung _____________________________________________________ 43
4.1.3.3.3. Sozialwissenschaftliche und ökonomische Forschungsthemen________________________ 45
4.1.3.4. Die Ergebnisse der Versuchsphase ________________________________________________ 47
4.1.3.4.1. Der Schweizer Synthesebericht________________________________________________ 47
4.1.3.4.2. Bericht der externen Expertenkommission zur Beurteilung der schweizerischen
wissenschaftlichen Studien über die ärztliche Verschreibung von Betäubungsmitteln
an Drogenabhängige ________________________________________________________ 50
4.1.4. Zusammenfassende Darstellung des Ablaufes der Entwicklung der kontrollierten
Heroinverschreibung – eine Chronik __________________________________________________ 65
4.1.5. Die Entwicklung der Schweizer Versuche nach der Versuchsphase __________________________ 68
4.1.5.1. Die legislative Regulierung – die drogenpolitische Auseinandersetzung ___________________ 68
4.1.5.2. Der drogenpolitische Diskurs ____________________________________________________ 68
4.1.5.2.1. Die Befürworter der HeGeBe _________________________________________________ 70
4.1.5.2.2. Verbände und Initiativen, die gegen die HeGeBe auftraten __________________________ 71
4.1.5.2.3. Das Referendum gegen den dringlichen Bundesbeschluss zur ärztlichen
Heroinverschreibung vom 9.10.1998 – Argumentarium_____________________________ 75
4.1.6. Die Entwicklung der Projekte zur HeGeBe _____________________________________________ 78
4.1.7. Situation 2001 ___________________________________________________________________ 80
4.1.8. Bislang vorliegende Ergebnisse der ersten Routinephase __________________________________ 81
4.1.9. Abschließende Bewertung des Schweizer Modells der heroingestützten Behandlung ____________ 83
4.1.10. Best Practice – Best Control? Das Schweizer Handbuch HeGeBe 2000, herausgegeben vom BAG 86
4.2. NIEDERLANDE___________________________________________________________________ 122
4.2.1. Die Niederländischen Studien und ihre Ergebnisse ______________________________________ 124
4.2.1.1. Ergebnisse __________________________________________________________________ 127
4.2.1.2. Die Kosten der HeGeBe im Niederländischen Modell ________________________________ 129
4.2.1.3. Schlussfolgerungen ___________________________________________________________ 129
4.2.1.4. Empfehlungen _______________________________________________________________ 130
4.3. DEUTSCHLAND __________________________________________________________________ 130
4.3.1. Der Entwicklungsprozess der deutschen Projekte _______________________________________ 130
4.3.2. Struktur, Dauer, Kosten und Rahmenbedingungen des deutschen Modellprojekts ______________ 133
4.3.3. Methode und Design _____________________________________________________________ 134
4.3.3.1. Studienaufbau _______________________________________________________________ 137
4.3.3.2. Zeitplan ____________________________________________________________________ 138
4.3.3.3. Voraussetzungen _____________________________________________________________ 138
4
4.3.3.4. Der aktuelle Stand des Projektes _________________________________________________ 138
4.3.3.5. Der bisherige Verlauf der Studie in Bonn __________________________________________ 138
4.3.3.6. Die deutsche und die niederländische Heroinstudie im Vergleich _______________________ 141
4.4. ENGLAND _______________________________________________________________________ 142
4.4.1. Drogenpolitischer Hintergrund _____________________________________________________ 142
4.4.2. Die Veränderungen in den sechziger Jahren des 20. Jahrhunderts __________________________ 144
4.4.3. Der Einsatz injizierbarer Zubereitungen in der Behandlung Abhängiger _____________________ 146
4.4.3.1. Das Ausmaß der Verschreibung von injizierbarem Methadon und injizierbarem DAM_______ 146
4.4.3.1.1. Aktuelle Situation _________________________________________________________ 149
4.4.4. John Marks: ein Traditionalist des „Britischen Systems“ _________________________________ 154
4.4.4.1. Bericht über die Behandlungsmethode von John Marks _______________________________ 156
4.4.4.1.1. Die abgegebenen Substanzen und ihre Darreichungsformen ________________________ 157
4.4.4.2. Arbeitsweise bis 1995 _________________________________________________________ 157
4.4.4.2.1. Die Arbeit der „drug dependency clinic“ von John Marks im Spiegel der Statistik _______ 159
4.4.4.3. Die Arbeitsweise nach 1995 ____________________________________________________ 160
4.4.4.4. Bewertung durch die örtlichen Strafverfolgungsbehörden _____________________________ 161
4.4.5. Die Verwissenschaftlichung der Opiatverschreibung an Abhängige in England________________ 161
4.4.5.1. Die Untersuchung von HARTNOLL 1980 _________________________________________ 161
4.4.5.2. Die Untersuchung von METREBIAN 1998 ________________________________________ 162
4.5. KANADA ________________________________________________________________________ 163
4.5.1. Drogenpolitischer Hintergrund _____________________________________________________ 163
4.5.2. Opiatgestützte Behandlung Abhängigkeitskranker ______________________________________ 164
4.5.3. Die Entwicklung des Heroinproblems ________________________________________________ 165
4.5.4. Die Entwicklung der Behandlung Opiatabhängiger______________________________________ 166
4.5.5. Die NAOMI – Initiative___________________________________________________________ 167
4.5.5.1. Das Konzept der NAOMI ______________________________________________________ 169
4.5.6. Laufende Heroinprojekte in Kanada _________________________________________________ 171
4.6. SPANIEN ________________________________________________________________________ 172
4.7. AUSTRALIEN ____________________________________________________________________ 173
4.7.1. Drogenpolitischer Hintergrund _____________________________________________________ 173
4.7.2. Der Entwurf des ACT ____________________________________________________________ 174
4.7.2.1. Zielvorstellungen und erwartete Ergebnisse ________________________________________ 174
4.7.2.2. Pilot-Studien ________________________________________________________________ 175
4.7.3. Australien 1997-2002 ____________________________________________________________ 176
4.7.3.1. Die drogenpolitische Diskussion _________________________________________________ 176
4.8. DÄNEMARK _____________________________________________________________________ 178
5. ZUSAMMENFASSENDE DARSTELLUNG________________________________________________ 179
5.1. Überblick über den internationalen Stand der heroingestützten Behandlung _____________________ 179
5.2. Die wissenschaftliche Ausrichtung der internationalen Experimente ___________________________ 179
5.2.1. Methodische Probleme der wissenschaftlichen Designs __________________________________ 180
5
5.2.2. Die Bedeutung der Projekte zur HeGeBe für die Forschung und die Bedeutung der Forschung
für die Praxis der HeGeBe _________________________________________________________ 184
5.2.2.1. Die problematischen Nebeneffekte der Forschungsauflagen für die Praxis ________________ 184
5.2.2.2. Beurteilung der Kritik _________________________________________________________ 185
5.3. Zusammenfassung der bisher vorliegenden Ergebnisse _____________________________________ 185
5.4. Die europäischen Studien im Überblick _________________________________________________ 187
5.4.1. Ergebnisse hinsichtlich der Zielvorgaben der Studien____________________________________ 187
5.5. Diskussion der Ergebnisse und Einschränkungen hinsichtlich ihrer Validität und Generalisierbarkeit _ 191
5.5.1. Bemerkungen zur Frage der „Haltekraft“ der Programme_________________________________ 191
5.5.2. Weiterhin offene Fragen __________________________________________________________ 192
5.6. Ein Zukunfts-Szenarium _____________________________________________________________ 194
5.6.1. Die Registrierung des DAM als Arzneimittel __________________________________________ 195
5.6.2. Die Position der Internationalen Suchtmittelkontrolle____________________________________ 196
5.7. Ausblick: Vorstellungen über die notwendige Differenzierung der heroingestützten Behandlung_____ 197
5.8. Schlussfolgerung und Empfehlung _____________________________________________________ 199
6. LITERATURVERZEICHNIS ____________________________________________________________ 203

Ein dicker Brocken, wie immer sehr interessant meiner wirklich ganz bescheidenen Meinung nach:

040622_expertise_heroinverschreibung

The Vienna Declaration/Drug War Statement Upstaged at AIDS Gathering

The Vienna Declaration

In response to the health and social harms of illegal drugs, a large international drug prohibition regime has been developed under the umbrella of the United Nations.1 Decades of research provide a comprehensive assessment of the impacts of the global “War on Drugs” and, as thousands of individuals gather in Vienna at the XVIII International AIDS Conference, the international scientific community calls for an acknowledgement of the limits and harms of drug prohibition, and for drug policy reform to remove barriers to effective HIV prevention, treatment and care.

The evidence that law enforcement has failed to prevent the availability of illegal drugs, in communities where there is demand, is now unambiguous.2, 3Over the last several decades, national and international drug surveillance systems have demonstrated a general pattern of falling drug prices and increasing drug purity—despite massive investments in drug law enforcement.3,4

Furthermore, there is no evidence that increasing the ferocity of law enforcement meaningfully reduces the prevalence of drug use.5 The data also clearly demonstrate that the number of countries in which people inject illegal drugs is growing, with women and children becoming increasingly affected.6 Outside of sub-Saharan Africa, injection drug use accounts for approximately one in three new cases of HIV.7, 8 In some areas where HIV is spreading most rapidly, such as Eastern Europe and Central Asia, HIV prevalence can be as high as 70% among people who inject drugs, and in some areas more than 80% of all HIV cases are among this group.8

In the context of overwhelming evidence that drug law enforcement has failed to achieve its stated objectives, it is important that its harmful consequences be acknowledged and addressed. These consequences include but are not limited to:

• HIV epidemics fuelled by the criminalisation of people who use illicit drugs and by prohibitions on the provision of sterile needles and opioid substitution treatment.9, 10
• HIV outbreaks among incarcerated and institutionalised drug users as a result of punitive laws and policies and a lack of HIV prevention services in these settings.11-13
• The undermining of public health systems when law enforcement drives drug users away from prevention and care services and into environments where the risk of infectious disease transmission (e.g., HIV, hepatitis C & B, and tuberculosis) and other harms is increased.14-16
• A crisis in criminal justice systems as a result of record incarceration rates in a number of nations.17, 18 This has negatively affected the social functioning of entire communities. While racial disparities in incarceration rates for drug offences are evident in countries all over the world, the impact has been particularly severe in the US, where approximately one in nine African-American males in the age group 20 to 34 is incarcerated on any given day, primarily as a result of drug law enforcement.19
• Stigma towards people who use illicit drugs, which reinforces the political popularity of criminalising drug users and undermines HIV prevention and other health promotion efforts.20, 21
• Severe human rights violations, including torture, forced labour, inhuman and degrading treatment, and execution of drug offenders in a number of countries.22, 23
• A massive illicit market worth an estimated annual value of US$320 billion.4 These profits remain entirely outside the control of government. They fuel crime, violence and corruption in countless urban communities and have destabilised entire countries, such as Colombia, Mexico and Afghanistan.4
• Billions of tax dollars wasted on a “War on Drugs” approach to drug control that does not achieve its stated objectives and, instead, directly or indirectly contributes to the above harms.24

Unfortunately, evidence of the failure of drug prohibition to achieve its stated goals, as well as the severe negative consequences of these policies, is often denied by those with vested interests in maintaining the status quo.25This has created confusion among the public and has cost countless lives. Governments and international organisations have ethical and legal obligations to respond to this crisis and must seek to enact alternative evidence-based strategies that can effectively reduce the harms of drugs without creating harms of their own. We, the undersigned, call on governments and international organisations, including the United Nations, to:

• Undertake a transparent review of the effectiveness of current drug policies.
• Implement and evaluate a science-based public health approach to address the individual and community harms stemming from illicit drug use.
• Decriminalise drug users, scale up evidence-based drug dependence treatment options and abolish ineffective compulsory drug treatment centres that violate the Universal Declaration of Human Rights.26
• Unequivocally endorse and scale up funding for the implementation of the comprehensive package of HIV interventions spelled out in the WHO, UNODC and UNAIDS Target Setting Guide.27
• Meaningfully involve members of the affected community in developing, monitoring and implementing services and policies that affect their lives.

We further call upon the UN Secretary-General, Ban Ki-moon, to urgently implement measures to ensure that the United Nations system—including the International Narcotics Control Board—speaks with one voice to support the decriminalisation of drug users and the implementation of evidence-based approaches to drug control.28

Basing drug policies on scientific evidence will not eliminate drug use or the problems stemming from drug injecting. However, reorienting drug policies towards evidence-based approaches that respect, protect and fulfil human rights has the potential to reduce harms deriving from current policies and would allow for the redirection of the vast financial resources towards where they are needed most: implementing and evaluating evidence-based prevention, regulatory, treatment and harm reduction interventions.

source and please sign there:http://www.viennadeclaration.com/the-declaration.html

Drug War Statement Upstaged at AIDS Gathering

VIENNA — Some of the world’s top AIDS experts issued a radical manifesto this week at the 18th International AIDS Conference: They declared the war on drugs a 50-year-old failure and called for it to be abandoned.
No one heard.

Officially, the theme of the AIDS meeting, the world’s largest public health gathering, is the need to attack the rapidly growing epidemic among addicts in Eastern Europe, Russia and Asia. It was held in Vienna because this city is the doorway to the East and, in this German-speaking country, all the conference signs are in English and Russian.

(In a lovely ironic touch, the conference hall is only a few steps from the Ferris wheel in the Orson Welles film noir classic set in postwar Vienna, “The Third Man.” On it, a cynical dealer of counterfeit drugs tells his pursuer to look down at the people below and says: “Victims? Don’t be melodramatic…. Would you really feel any pity if one of those dots stopped moving forever?”)

But the organizers’ efforts to get publicity for the Vienna Declaration, which calls for drug users to be spared arrest and offered clean needles, methadone and treatment if they have AIDS, have come to naught. Almost no one here talks about the war on drugs.

Instead, everyone is publicly worrying that the war on AIDS is falling apart. Donor money is evaporating in the recession, and it is looking likely that only about a third of the 33 million infected people in the world will have any hope of treatment.

Frustration is high. Speakers like Bill Gates were interrupted by demonstrators in Sherwood Forest green calling for a “Robin Hood tax” — a tiny fee on the $4 trillion in currency transactions made daily by banks and hedge funds that could raise billions for AIDS.
Many activists blame the Obama administration, which is shifting its priorities to mother-and-child health. The halls are decorated with posters comparing Mr. Obama unfavorably with George W. Bush. On Wednesday, Archbishop Desmond Tutu criticized Mr. Obama in an Op-Ed article in The New York Times.

In his speech here, former President Bill Clinton said Ambassador Eric Goosby, the administration’s global AIDS coordinator, “ought to get some kind of Purple Heart for showing up.”
However, a new report from the Kaiser Family Foundation shows that the United States still gives more for AIDS assistance than all other countries put together, accounting for 58 percent of contributions. Its donations are still going up slightly, while those from Europe, Canada, Japan and Australia are flat or falling.

Officials from the Global Fund to Fight AIDS, Tuberculosis and Malaria say they fear they will not come close to the $17 billion target they set for their next donors’ meeting in September.
The other, more welcome, distraction has been the exciting results of a South African clinical trial in which a vaginal gel with an antiretroviral drug protected 40 percent of the women using it. This is the first good news about microbicides in decades of work. A gel women can use secretly has long been sought, since many men disdain condoms and many women want to get pregnant.

The Vienna Declaration is only the second time that the International AIDS Society has issued such a document. The last was the 2000 Durban Declaration, which reaffirmed that H.I.V. was the cause of AIDS. It was a response to the government of South Africa, the conference’s host, which at the time denied that the virus caused disease and refused to buy medicine for its citizens.

Outside of Africa, almost a third of all H.I.V. infections stem from drug injections.
The declaration contends that arresting drug users forces them into hiding, spreading the epidemic. It backs “science-based public health approaches“ proved in clinical trials, which can include everything clean needle swaps, 12-step recovery programs and methadone.

Dr. Evan Wood, an AIDS policy expert at the University of British Columbia and the chief author, cited Portugal’s approach. According to a 2009 report by the libertarian Cato Institute, in the decade since Portugal legalized possession of up to 10 days’ worth of any drug, including cocaine and heroin, its AIDS rate dropped by half, overdose deaths fell, many citizens sought treatment, drug use among young people fell and drug tourism did not develop. The institute called the policy “a resounding success.”
The declaration is largely aimed at countries of the former Soviet Union. In Russia, for example, close to 1 percent of its adult population is infected.

Nonetheless, the country forbids all methadone-type treatments, and the national health plan offers only abrupt detoxification, which has a high failure rate. The most frequent victims — prisoners and people not living in their assigned residence areas — are the least likely to get AIDS drugs, and activists say markups vastly inflate the prices of medications bought cheaply by foreign donors.

“The government says everything is fine,” said Aleksandra Volgina, 31, the leader of Candle, a Russian AIDS organization based in St. Petersburg. “We’re even donors to the Global Fund, but we don’t have treatment; we don’t even have prevention.”
She has stayed off heroin thanks to a 12-step program her family paid for, she said, but every month she worries about whether the government pharmacy will have all three drugs she needs, and some of her friends have died for lack of them.
“What’s going on in Russia is being silenced,” she said. “You can’t even knock on the Health Ministry’s door.”

Despite the quasi-Russian cast to the conference, no one from the Russian government attended, sponsors said.
Only two governments reacted to the declaration: Canada, which rejected it, and Georgia, whose first lady signed it in a public ceremony. The tiny former Soviet republic has a history of brutal treatment of drug addicts, Dr. Wood said. But it also has taken to defying Russia, with which it fought a brief war in 2008.

In the large American delegation here, almost every top official refused to discuss the declaration. Finally, one government official, speaking on the condition of anonymity, said he had just called the White House for guidance and was told no one had read it yet and there was no time to respond.

He did note that Dr. Goosby recently announced that countries getting American help to fight AIDS can use it to buy clean needles for addicts, a change from Bush administration policy.
The one exception to the official American silence was Dr. Nora D. Volkow, the normally low-profile director of the National Institute on Drug Abuse, who said she personally agreed with the declaration’s premise.
“Addiction is a brain disease,” she said. “I’m a scientist. The evidence unequivocally shows that criminalizing the drug abuser does not solve the problem. I’m very much against legalization of drugs or drug dealing. But I would not arrest a person addicted to drugs. I’d send them to treatment, not prison.”

Asked if she feared being attacked by Congressional conservatives, she said: “I took this job because I want drug users to be recognized as people with a disease. If I don’t speak about it, why even bother to gather the data?”

Heroin May Protect the Brain from HIV!

To their surprise, researchers at Georgetown University Medical Center (GUMC) have discovered that morphine (a derivate of the opium poppy that is similar to heroin) protects rat neurons against HIV toxicity – a finding they say might help in the design of new neuroprotective therapies for patients with the infection.

The discovery, being presented at the annual meeting of the Society of NeuroImmune Pharmacology, also helps explain why a subset of people who are heroin abusers and become infected with HIV through needle sharing don’t develop HIV brain dementia. This brain disorder includes cognitive and motor abnormalities, anxiety and depression.

„We believe that morphine may be neuroprotective in a subset of people infected with HIV,“ says the study’s lead investigator, Italo Mocchetti, PhD, Professor of neuroscience at GUMC. „That is not to say that people should use heroin to protect themselves – that makes no medical sense at all – but our findings gives us ideas about designing drugs that could be of benefit.

„Needless to say we were very surprised at the findings,“ he added. „We started with the opposite hypothesis – that heroin was going to destroy neurons in the brain and lead to HIV dementia.“

The researchers conducted the study because they knew that a number of HIV-positive people are also heroin abusers, and because of that, some are at high risk of developing neurological complications from the infection. Others, however, never develop these cognitive problems, Mocchetti says.

Because little is known about the molecular mechanisms linking opiates and HIV neurotoxicity, Mocchetti and his team conducted experiments in rats. They found that in the brain, morphine inhibited the toxic property of the HIV protein gp120 that mediates the infection of immune cells. With further investigation, they concluded that morphine induces production of the protein CCL5, which they discovered is released by astrocytes, a type of brain cell. CCL5 is known to activate factors that suppress HIV infection of human immune cells. „It is known to be important in blood, but we didn’t know it is secreted in the brain,“ says Mocchetti. „Our hypothesis is that it is in the brain to prevent neurons from dying.“

They say morphine blocked HIV from binding to CCR5 receptors it typically uses to enter and infect cells. The researchers believe CCL5 itself attached to those receptors, preventing the virus from using it. In this way, it prevented HIV-associated dementia. This effect, however, only worked in the M-trophic strain of HIV, the strain that most people are first infected with. It did not work with the second T-trophic strain that often infects patients later.

„Ideally we can use this information to develop a morphine-like compound that does not have the typical dependency and tolerance issues that morphine has,“ says Mocchetti.

April 17, 2010
Red Orbit
http://www.redorbit.com/news/health/…rain_from_hiv/