The Emerging Role of Inhaled Heroin in the Opioid Epidemic

9/4/2018

William Haning, MD, DFASAM, DFAPA

published in ASAM

U.S. Deputy Attorney General Rod Rosenstein’s guest editorial for 27 August (New York Times) is linked below.  It is an important perspective to read. Mr. Rosenstein argues for the abandonment of a trend in urban centers of establishing safe sites for conducting injection drug use (Safe Injection Sites, or SISs). He maintains that more of a penal approach to drug distribution is needed, stating that there is evidence that currently reactive Federal drug policy is achieving significant improvements in diminishing drug use. The editorial’s strongest basis for opposing SISs appears to be that the facilities do not show a justifying rate of recovery from substance use disorders.This will predictably yield a wave of opposing commentary, centered on what seems to be a missed point:  the principal purpose of the SISs is not to treat addiction. It is to reduce collateral damage. There is an obligation, founded in humanity, to diminish harm in any population. The SISs have been repeatedly demonstrated not so much to encourage drug use, which will occur regardless the venue, as to encourage medically safeuse.  They are deployed in communities with limited resources as a means of controlling the spread of HIV, hepatitides A/B/C (sic), and blood-borne infections resulting in severe heart, lung, renal, hepatic and joint disease; and with the hope of rapid intervention in the event of overdose. The other aim is that in conserving health, the opportunity to enter recovery is lengthened. Any effectiveness of suppressing endemic drug use through prosecution, particularly of distributors who are themselves addicted, needs another, larger forum.

There was no shortage of controversial opinionizing, this past week.  Again in the New York Times, 31 August 2018 (Opinion, https://www.nytimes.com/2018/08/31/opinion/addiction-recovery-survivors.html ), Maia Szalavitz employs a series of testimonials to support the contention that, as titled, “Addiction Doesn’t Always Last a Lifetime.” The vignettes of peoples’ lives and their respective recoveries are at turns gritty, poignant, and lovingly hopeful; and give insight to the cultures of addiction.  But the fundamental premise provided at the outset is that “…almost all of those who once met criteria for prescription opioid-use disorder achieved remission during their lifetimes — and half of those recovered within five years. “The comment is drawn from a 2013 article in the Journal of Psychiatric Research, based on the NESARC survey and linked within the piece (https://www.ncbi.nlm.nih.gov/pubmed/22985744 ); but there is perhaps insufficient emphasis on the article’s study question, which was of prescription drug use.This risks setting a flash fire of reactive indignation and anger, when in fact the fundamental point that the author seems to want to make – that there are many routes to recovery – is a good one.

– W Haning, MD