MORE PANIC IN NEEDLE PARK

The first detailed account of a heroin drought was in the American novel Panic in Needle Park by James Mills. More recently we have had empirically based accounts from Australia, and this paper by Louisa Degenhardt and colleagues (Degenhardt et al. 2005) is one of many interesting publications from that country describing the drought and its consequences. The paper is an excellent addition to the literature on what is a surprisingly rare phenomenon (surprising, as every year the most powerful governments in the world and their associated organizations spend billions of dollars in trying to produce precisely this effect). The paper reports a number of effects of the drought. Of these the most striking is, perhaps, the reduction in heroin-related deaths (as well as non-fatal overdoses), with no increase in deaths related to other drugs. This is an extremely important finding and one to be greatly welcomed. Mortality should not be passively accepted as an intrinsic hazard of drug misuse. Such deaths are not inexplicable; nor are they impossible to prevent. However, some of the other findings seem less secure. For example, I was not entirely convinced that a decline in injecting drug use could be safely inferred from a reduction in the number of needles and syringes distributed. There was a transfer of drug use from heroin to methamphetamine and cocaine which may involve more frequent injections and less predictable drug use behaviours, and this must raise the possibility that any switch to the injection of stimulants could lead to lower rates or less frequent attendance at needle exchange schemes. Indeed, the authors themselves acknowledge that the limited availability of treatment options for stimulant users may have limited their contact with treatment services. A study of out-of-treatment drug misusers would have provided better information on this matter. Nor is it clear what are the longer-term implications of any such switch from injection of heroin to injection of methamphetamine. In this respect, I was interested in the finding of Degenhardt et al. (2005) that there was a differential impact of the heroin shortage within user groups: older users were found to show less reduction in drug-related harms, and marginalized users may have switched to riskier forms of injecting drug use. In this, and in one or two other areas, I was slightly uneasy that the authors were able to summarize the effects as representing ‘an aggregate positive impact’; I would have preferred a more explicit statement of ‘costs’ and ‘benefits’. However, the significance of this paper is to be found not only in its specific findings, but also in the interpretations of the results, and in the implications that might be drawn from the findings. Put succinctly, does the heroin drought and its effects provide a vindication of supply reduction interventions? This is precisely what has been claimed both within Australia and internationally. The Liberal-National Party Government in Australia has cited the heroin drought and its effects as evidence of the success of their ‘tough on drugs’ law enforcement strategy. Similarly, the 2003 Annual Report of United Nations International Narcotics Control Board asserted confidently that the reduction in heroin use was due to ‘successful interdiction activities at its [Australia’s] border and co-operation with national authorities in South-East Asia’. In view of the fact that supply reduction measures swallow the vast majority of the resources available for tackling drug misuse problems, any evidence to support their effectiveness would be valuable. But the Australian heroin drought is a more complicated phenomenon and cannot be so easily explained. Others have argued that the shortage had little to do with interdiction and interception of heroin shipments (Dietze & Fitzgerald 2002). Nor is it certain that the implications of the disruptions in the heroin supply chain that occurred in the unique circumstances of Australia can be generalized readily to other countries. After the seizure by Canadian police of approximately 100 kg of heroin, Wood et al. (2003) found no changes in heroin use or frequency of overdoses, and concluded that this massive heroin seizure had no measurable public health benefit. In London, what the Metropolitan Police described as its ‘biggest ever drug operation’, and as a ‘spectacular success’, and which led to the seizure of drugs with an estimated street value of £1.5 million, had little or no observable impact on drug markets or drug users (Best et al. 2001). A clearer interpretation of the Australian heroin drought may come only from tracking changes over time. To what extent was the drought itself a one-off event? If it represented the successful achievement of supply reduction measures, let us look forward to more examples of success in the reduction of heroin availability. Also, to what extent can we expect the changes in drug-related problems that are reported in this paper to endure? I look forward to hearing more about the longer-term effects of the drought.

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