AVOIDING SIMPLISTIC INTERPRETATIONS: COMMENT ON DEGENHARDT <i>Et al</i>. 2005

The Australian heroin shortage of 2001 is a fascinating natural experiment on the impact of drug supply on subsequent drug use and associated harms. Using a number of existing administrative data sources, Degenhardt and colleagues were able to show dramatic reductions in heroin-related deaths, ambulance call-outs for drug overdoses and police incidents for heroin possession/use [1]. As would be anticipated, the major impact was in the states of New South Wales and Victoria, where the heroin market was well established. The study did not show a decrease in criminal activity or an increase in the number of individuals receiving addiction treatment. One possible, yet erroneous, interpretation of these findings is that aggressive supply reduction efforts should be pursued in order to reduce the adverse consequences of illicit drug use. The global response to reducing the catastrophic health and social consequences of injection drug use has been focused overwhelmingly on supply side strategies. In Canada, for example, it is estimated that over 93% of our $500 million national drug strategy goes toward supply reduction [2]. Through a number of external measures, such as drug use prevalence, crime statistics and health outcomes, this response has failed miserably [3]. A continued focus on criminal punishment for those who are drug dependent only worsens the health and social consequences for that individual, as well as the affected community. In Vancouver, a highly publicized seizure of 100 kg of heroin in 2000 had no impact at the street level on price, purity or overdose rates [4]. It should be noted that in the case of Australia, enforcement efforts were not linked to the reduced heroin supply. Communities that support a heroin market must have both a consistent source of heroin and enough people to purchase the drugs. If the drug supply suddenly dries up, as was the case in Australia, the options for the individual are to simply stop using heroin, seek addiction treatment, replace one drug with another or find heroin in another location. Although this study was not able to document individual drug use, it would be highly unlikely that regular heroin users would abruptly stop using. It is surprising that there was no increase in the uptake of opioid pharmacotherapy programs if people were facing opiate withdrawal. In fact, there was a marked decrease in the numbers of new treatment clients. There was evidence for drug substitution with methamphetamine, cocaine and benzodiazepines, although morphine or other opiates would have been the more likely drugs of substitution. The study was not able to determine the number of heroin users who left their communities in search of opiates although the heroin shortage appeared to be countrywide. Overall, the impact of the heroin shortage on individual behaviors could not be determined easily from this study. Heroin and other illicit drugs have become entrenched in the landscape of many cities around the world, driven largely by poverty, despair and social breakdown. HIV and hepatitis C epidemics among injection drug users have brought a new urgency to apply innovative interventions to reduce the burden of illness and death associated with addiction. A comprehensive strategy that includes prevention, treatment, harm reduction, social supports and supply reduction are needed, with the ultimate goals of decreasing the acute and long-term health risks, expanding treatment and improving the underlying social and environmental conditions that perpetuate the misuse of illicit drugs. The impact of a sudden and sustained reduction in heroin availability, although showing some compelling health benefits in the short term, captures only a small piece of the addiction dilemma.

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