LEARNING FROM UNCOMMON EVENTS: COMMENT ON DEGENHARDT Et al. 2005

Abstract

The literature contains several studies of the fallout from relatively rapid increases in the availability of illicit heroin (Robins 1993; Strang & Gossop 1994; DuPont 2002). Typically, use rates, overdose deaths and acquisitive crime increase; and with some latency, so does treatment seeking where treatment is available. In contrast, there are few studies of what happens to drug users and their communities when opioid availability abruptly decreases. Such a temporary decrease occurred in the United States in 1972/1973, after the United States persuaded Turkey to cease harvesting opium and adopt the poppy straw extraction method for producing the raw material for medicinal opioids. At the time, only a limited number of indicators of the effects of the heroin shortage were in place. Some of those, such as treatment seeking, were of limited value because there was already excess demand for available treatment capacity; needles were not yet being distributed. The present study by Degenhardt et al. (2005) of the effects of a sharp decrease in heroin supply, with multiple measures of its impact on users and the community in place, may be unique in the scientific literature. Any comment should begin by commending the authors and their colleagues for this and related important contributions dealing with such an episode of reduced heroin supply in Australia (Degenhardt et al. 2005; Gibson et al. 2005). Degenhardt and colleagues provide some assurances that one of the possible unintended consequences of reduced heroin supply will not materialize. Over the past 15–20 years, heroin users in the United States and the United Kingdom have increasingly shifted from injecting opiates to using them intranasally (snorting) or inhaling them (chasing the dragon) (Griffiths et al. 1994). About 50–60% of heroin users on the east coast of the United States who seek treatment claim that they use heroin exclusively by the intranasal route (Neaigus et al. 2001). This shift in preferred route of administration has been driven largely by concerns about HIV infection and has taken place even though sterile injection equipment has become more widely available. Most probably it has also been facilitated by the declining price of illicit heroin that is occurring, even though resources devoted to supply reduction have increased substantially. This decline in the price of heroin in the United States is likely to have been a factor in a resurgence of heroin use among some young people. There is concern in the United States, however, that a sharp decrease in availability or a substantial increase in price could lead to increased injection use because of the greater efficiency of this route. Degenhardt and coworkers suggest that this should not be a major concern because during the heroin shortage in Australia all the indices of drug injecting dropped, including the distribution of sterile needles, and no sharp increase in the demand for treatment ensued. This study also indicates that the expected increases in acquisitive crime are only transient. However, another report on the Australian heroin shortage (Gibson et al. 2005) takes a somewhat different tone, describing the burdens experienced by treatment personnel trying to cope with a new wave of amphetamine- and benzodiazepine-induced toxicities as heroin users substituted those drugs for heroin. Nevertheless, even without a formal cost–benefit analysis, the findings appear to provide support for an overall benefit from decreasing heroin availability. That much said, we should also note that the decrease, although sustained for several months, did not persist. The illicit trade rose again. As it is difficult to predict when such reductions in availability can again be achieved we would do well to continue to improve our capacity to reduce heroin-related harms in the presence of continued availability. It would be important to try to confirm the findings of this landmark study. In contrast to the situation in 1972, the United States now has in place many of the monitoring systems that would allow a comparable assessment of the impact of a sharp curtailment in the supply of heroin. Now what we need is a sharp and sustained shortage.