Today’s policy boner


So I have a shameful secret to divulge: I get viscerally, enthusiastically, quasi-orgasmically happy about evidence-based policy. Some people get a little thrill in their nether regions when their favourite celebrity is on TV, or when their sports team wins an important game, or when their favourite band announces a new album. All of those, to me, pale in comparison to the rock-hard excitement I get when someone does something really cool in policy research.

So (and he knows me personally, so please don’t repeat this or it’ll get weird) Dr. Aslam Anis, you’ve given me a boner:

Prescribing heroin instead of methadone is more effective and less costly in treating street drug addiction relapses, a new analysis suggests. It was a collaboration with UBC, the University of Montreal and the Northern Ontario School of Medicine.

“We gave them option of trying methadone or diacetylmorphine [heroin] under medically supervised conditions, and we found people who were getting diacetylmorphine were retained in treatment much, much longer, so they had a much better outcome,” said study head Dr. Aslam Anis, director of the Centre for Health Evaluation and Outcome Sciences at St. Paul’s Hospital in Vancouver.

(snip)

“Our model indicated that diacetylmorphine would decrease societal costs, largely by reducing costs associated with crime, and would increase both the duration and quality of life of treatment recipients,” the study’s authors concluded. While the clinical trial was based on a year’s worth of data, the researchers considered different timeframes — such as one year, five years and over a lifetime— in their analysis.

Now my writing about this article flirts dangerously with talking about my work life, but I feel like it’s remarkable enough to warrant a slight blurring of the lines. We’ve talked about Vancouver’s drug policy before, in the context of using the evidence rather than the memetic approach preferred by governments (and particularly by this one). It’s therefore entirely possible that we may see this piece of data make its way into policy.

Of course, there is a petty element to my joy. Obviously I want to see the promotion of whatever option is the most effective at helping people to kick their substance addiction. Whatever the evidence says is the best, let’s do that. However, this finding is also a nice thumb in the eye of the “drugs iz bayud” crowd – drug use is not a moral imperative that must be condemned on its face. Drugs are only harmful insofar as they are often accompanied by negative consequences like addiction or health problem – removing or mitigating those consequences eliminates the ‘bad’ of drugs. The only remaining objection then becomes “I don’t like drugs”. Okay, cool. Neither do I. Doesn’t mean they must be made illegal.

And, as paradoxical as it may seem, this analysis suggests that drugs may be the best tool to reduce drug dependency. Yes, it sounds silly, but the evidence is fairly clear (and reproduced in other jurisdictions) – heroin works better than a heroin substitute in helping people to wean themselves off of heroin. There’s also, believe it or not, a cost ‘savings’ associated with using the real drug rather than the substitute – not because the purchase point is lower, but as a byproduct of the downstream effectiveness of keeping people in rehab programs for a longer period of time.

It should be noted that this isn’t policy yet, and there may be a conservative anti-science backlash against “giving addicts more drugs” or something similarly free of nuance. However, if the widespread public support for Insite – couched as it was in deference to evidence over ideology – is any indication of Vancouver’s attitude toward policies that lie outside the political mainstream, we may see an exciting (and evidence-based) new direction for my home town.

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Comments

  1. Happiestsadist says

    I feel the same way about evidence-based policy. *fans self*

    The idea of actually helpful public policy that’s grounded in reality instead of ideology and punitive authoritarianism makes me all excited.

  2. Not my real name says

    Commenting not under my real name, for reasons that will soon be obvious (but Crommie will see from the e-mail I am a a regular commenter and not a drive-by troll or anything)….

    The other thing about this is that the ubiquity of methadone as a heroin substitute in treatment programs has made it a street drug itself — and a nasty one at that.

    Back before my wife and I had kids, we both were definitely down for a “party” pretty much whenever: I never injected anything, but beyond that, you name it and I probably tried it at least once. One time, the guy who used to sell us coke gave my wife some random pill, which turned out to be methadone. Laid her out the entire next day. There’s not a whole lot of drugs where I’m like, “Nobody should ever do that, ever” — but methadone is one.

  3. Sneffy says

    I’m curious, how does a treatment that prescribes heroin actually go about breaking the dependency? Do they slowly decrease dose size/frequency?

  4. julian says

    Sweet.

    Just got out of an hour long argument with a coworker about cases where drugs should be legalized. Managed to (finally) get him to agree if a drug could be shown to be more effective than substitutes in helping patients overcome their addiction it should be used.

    Hopefully this will shut him up.

    More than likely it’ll probably make him revert to his purist ‘you should just quit’ stance.

  5. 'Tis Himself, OM says

    All of those, to me, pale in comparison to the rock-hard excitement I get when someone does something really cool in policy research.

    Everyone needs a hobby.

  6. says

    Seems rather counter-intuitive, but . . . I suppose. I used the nicotine patch to get off of cigarettes (I may be the only ex-smoker that misses it), so I guess that’s analogous. Although, I’m not aware of any nicotine substitute.

    (I’m well aware that I’m using pure, personal anecdote to wrap my brain around this idea)

  7. Tiffany says

    I love evidence-based policy too but I couldn’t decide whether I was really excited or cautiously optimistic! The reason is that the article was a bit confusing. On one hand, there is this statement:

    “We gave them option of trying methadone or diacetylmorphine [heroin] under medically supervised conditions, and we found people who were getting diacetylmorphine were retained in treatment much, much longer, so they had a much better outcome,” said study head Dr. Aslam Anis, director of the Centre for Health Evaluation and Outcome Sciences at St. Paul’s Hospital in Vancouver.

    Then it says this:
    Most of the savings in the mathematical model were attributed to how those prescribed heroin stayed in treatment longer and spent less time in relapse than those randomly assigned to receive methadone.

    So I’m having trouble figuring out which parts of the study were randomized and which parts relied on individual choice. Those things matter, as one could argue that people who chose the methadone might have been systematically different (e.g. more hardcore or long-term users) and that might have affected the results. I am going to try to search for the original study so that I can wrap my head around this a little better. (On a completely unrelated note, can someone help this new commenter with the quote function??)

  8. Dianne says

    I get viscerally, enthusiastically, quasi-orgasmically happy about evidence-based policy.

    Epidemiologists have such weird fetishes*. Not the easiest one to satisfy either given the rarity of evidence based policies.

    Related question: Is the goal of this program universally abstinence or is there a harm reduction component as well? Harm reduction programs may be more appropriate for people for whom abstinence isn’t a reasonable goal (i.e. patients with sickle cell anemia and pain requiring chronic opioids). But it’s hard to get a politician to support a program that ends up with people continuing to use opiates, even people in these programs end up using the minimum necessary dose of opiates, going to school/work with good grades/performance reviews, not committing any crimes, and raising a family with 2.3 kids and a schnauzer.

    *Though honesty compels me to admit that I feel much the same way.

  9. says

    “The only remaining objection then becomes “I don’t like drugs”. Okay, cool. Neither do I. Doesn’t mean they must be made illegal.”

    I like this philosophy. It matches much of my own.

    Overall, harm-reduction just seems to be the way to go, and if heroin works best at getting people through treatment, then we should prescribe heroin. As the regular commenter under a different named noted…methadone is becoming/has become a street drug. So there’s really no difference there anyway.

    Do what works.

  10. says

    That’s how it works, yes. Although generally you only reduce the dosage, not the frequency. Lengthening the intervals doesn’t work nearly as well as far as I know. It has weird psychological effects on some people, at least.

  11. says

    It seems entirely intuitive that the real thing would be more effective than an substitute. The part that amazes me is that no one thought to test this sooner. Indeed, I’m reasonably sure that this has been examined before — at least with other drugs — and the result was the same.

  12. says

    Drugs are only harmful insofar as they are often accompanied by negative consequences like addiction or health problem – removing or mitigating those consequences eliminates the ‘bad’ of drugs.

    Also among the negative consequences: otherwise untreated mental illness. If people can eventually have their self-prescribed opiates (e.g.) replaced with physician-prescribed SSRIs or lithium or whatever is called for, plus whatever therapy they might need, all to the good.

  13. says

    I would be hesitant to get excited, as this seems to be “policy research” as opposed to “policy”. Anyone who has been involved to any degree in government knows that policy recommendations rarely to never translate to policies based on the reccomendations.
    Especially under a Conservative government.

    That said, I applaud the study. Our national drug policy is ineffective, costly, and often unnecessary. Drugs become a form of “double jeopardy”- where we make the corrallary symptom illegal in an effort to avoid illegal behavior that is already punishable.

  14. says

    Tiffany @11

    <blockquote>Crommunist is a bloody genius</blockquote>
    will render the text in quotes as this:

    Crommunist is a bloody genius

    I hope that helps both you and Crommunist, for different reasons. ;)

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