1 APPENDIX A INFORMATION PAMPHLET ON HEROIN AND OTHER NARCOTIC ANALGESICS Reprinted with the permission of The Drug Offensive. 2 APPENDIX A Heroin and other narcotic analgesics. General facts. NARCOTIC ANALGESICS. These include the naturally occuring drugs extracted from the Asian poppy plant, opium, and its constituents codeine and morphine, the semi-synthetic derivations of morphine such as heroin; and wholly synthetic drugs such as pethidine, methadone, and pentazocine (Fortral*). OPIOIDS. Opioid is a term covering all narcotics including natural opium derivates, semi-synthetic and synthetic narcotics. Opioids can be found in the juice extracted from the seed pod of the Asian poppy Papaversomniferum. The drugs derived from this extract include opium and its constituents, codeine and morphine, as well as their derivatives, such as heroin. Natural derivates of opium are known as OPIATES. The opioids have been used both medically and recreationally for centuries. A tincture of opium called laudanum has been widely used since the 16th century as a remedy for 'nerves' or to depress coughing or stop diarrhoea. By the early 19th century, morphine had been extracted in a pure form suitable for solutions, and with the introduction of the hypodermic needle in the mid-19th century, injection of the solution became the common method of administration. Heroin (diacetylmorphine) was first marketed in 1898 for general medical use and was heralded firstly as a cough suppressant, then in 1900 as a remedy for morphine addiction. Of the 20 alkaloids contained in opium, only codeine and morphine are still in widespread clinical use today. In this century, many synthetic drugs have been developed which have essentially the same effects as the natural opium alkaloids. The opioid-related synthetic drugs, such as pethidine and methadone, were developed to provide an analgesic without dependence-producing properties. Unfortunately, however, all the opioids and their synthetic derivatives which are effective as analgesics are also dependence producing. Modern research has led to the development of another family of drugs called narcotic antagonists (eg naloxone hydrochloride). These drugs are not used as painkillers, but to reverse the effects of opioid overdose. Since administration can also initiate immediate withdrawal they are often used to gauge the level of physical dependence in clients requesting treatment. Effects. As with any drug, the effects of narcotic analgesics depend on the AMOUNT taken at one time; the MANNER in which it is taken (duration, frequency, route of administration, use of other drugs); the INDIVIDUAL (age, sex, health, body weight, mood, tolerance, past experience and activities of the user); and the CIRCUMSTANCES in which the drug is taken (the place, the presence of other people). Immediate effects. THE PHARMACOLOGICAL ACTIVITIES OF THE NARCOTICS ARE: Analgesia (relief of pain). Euphoria (a feeling of well-being) - this effect may be directly associated with the analgesic effect. Production of nausea and vomiting. Depression of respiration - the cause of death from overdose. Reduction of movements of the bowel (intensive constipation). Miosis (constriction of the pupils of the eyes). 3 The main therapeutic application of the narcotics is for the relief of severe pain. The drug effect is not on the perception of pain but rather upon its interpretation by the brain. Typically, the patient is aware that the pain is still present, but it is no longer interpreted as being painful or disturbing. The euphoric and dependence-producing capacity of these drugs is probably directly associated with this action. Other therapeutic applications are for cough suppression and treatment of diarrhoea. Synthetic and semi-synthetic derivatives have been made and selected for their specificity for these actions with a minimum of dependence- producing capability. Narcotics briefly stimulate the higher centres of the brain, then depress the activity of the central nervous system. Immediately after injection the user feels a surge of pleasure ('a rush') which gives way to a state of gratification into which hunger, pain and sexual urges usually do not intrude. The dose required to produce this effect may initially cause restlessness, nausea and vomiting. The effects of a usual dose in a therapeutic setting lasts approximately 3 to 4 hours. With moderately high doses the body feels warm, the extremities heavy and the mouth dry. The user goes "on the nod', an alternately wakeful and drowsy state during which the world is forgotten. As the dose is increased, breathing becomes progressively more depressed. With very large doses the person cannot be roused, the pupils are contracted to pinpoints, the skin is cold, moist and bluish, and profound respiratory depression resulting in death may occur. Effects of short-term use. The main problems of short-term use are associated with the manner of administration. The illicit use of narcotics presents many dangers. As supply is illegal, composition is unknown. The concentration of heroin (or other narcotics) varies considerably as each drug dealer further dilutes (cuts) the sample with other substances. A fatal overdose may arise from the use of a sample which contains more narcotic than those samples previously purchased. Furthermore, the materials used for 'cutting' may be active drugs, such as strychnine, barbiturates, amphetamines and caffeine, or inactive substances like talcum powder or even household cleaners. Large insoluble particles constitute a danger when injected intravenously - they may obstruct small blood vessels, in the eye or the brain for example. The intravenous use of any drug carries with it a danger of infection. The incidence of serious infection, such as serum hepatitis, is extremely high among intravenous users of drugs, due to the use of unsterilised, and often shared, needles. This group of drug users also runs the risk of being exposed to the Acquired Immune Deficiency Syndrome (AIDS) virus. Effects of prolonged use. The narcotic analgesics, in pure form and administered cleanly, are non-toxic to body tissue. If not administered cleanly in pure form, chronic opioid users may develop endocarditis, an infection of the heart lining and valves by organisms introduced into the body during injection of the drug. Abscesses, cellulitis, liver disease, and possibly brain damage may also result from infections associated with unsterile injection techniques. Tetanus is common among users with a long history of subcutaneous injection. Pulmonary complications, including various types of pneumonia, may also occur due to lifestyle and the effects of narcotics on respiration. The main problem associated with the prolonged usage of narcotics is the development of tolerance and a withdrawal syndrome. In the therapeutic situation, these problems can be avoided or minimised by carefully regulating the interval between doses. Tolerance and dependence. TOLERANCE exists when increased doses of the drug are needed to produce the same effects as initially achieved 4 at lower doses. DEPENDENCE exists when a drug is so central to a person's thoughts, emotions and activities that it is very difficult to stop using it, or to maintain very reduced consumption. Some indicators of dependence are compulsion or craving to use, increased tolerance and sometimes withdrawal symptoms. Regular use of opioids produces tolerance. Regular users may also become dependent on opioids. WITHDRAWAL from opioids, which may occur as early as a few hours after the last administration, produces uneasiness, yawning, tears, diarrhoea, abdominal cramps, goosebumps and a runny nose. These symptoms are accompanied by a craving for the drug. The most marked withdrawal indicators peak between 48 to 72 hours after the last dose and subside over a week. Some bodily functions do not return to normal levels for as long as six months. Sudden withdrawal by heavily DEPENDENT users who are in poor health has occasionally been fatal. However, opioid WITHDRAWAL is much less dangerous to life than the alcohol or barbiturate withdrawal syndromes. Opioids and pregnancy. Most drugs have some effect on the unborn child. Therefore, pregnant women or women considering having a child need to consult their doctor about their current or potential drug use. Research has shown that approximately half of all opioid-dependent women experience complications during pregnancy and childbirth. Anaemia, cardiac disease, diabetes mellitus, pneumonia and hepatitis are among the most common medical problems. These women also demonstrate an abnormally high rate of spontaneous abortion, breech delivery, Caesarean section, and premature birth. Opioid withdrawal has also been linked to a high incidence of stillbirths. Infants born to opiod-dependent mothers are smaller than average and frequently show evidence of acute infection. The majority exhibit withdrawal symptoms of varying degrees and duration. The mortality rate among these babies is also higher than normal levels. Who uses opioids? A small proportion of those for whom opioids have been prescribed in medical treatment become dependent. Even codeine use continued inappropriately may get out of control. In such cases, medical advice should be sought, since withdrawal symptoms may result from abrupt cessation after high tolerance has been established. The largest proportion of inappropriate opioid use falls, however, into the street-use category. During the past few years, synthetic narcotics such as hydrocodone, hydromorphone, oxycodone, and pethidine have gained prominence as drugs of dependence. Physicians are sometimes pressured to provide prescriptions for these medications. They are also stolen from pharmacies, sold on the street, and used illegally. Today inappropriate use of other narcotic-based medicines such as Percodan*, Dilaudid*, Palfium* and Physeptone* is common. THERAPEUTIC USES. Opioids which are legally and pharmacologically classed as narcotics are used in modern medicine to relieve the acute pain suffered as a result of disease, surgery or injury, in the later stages of such terminal illnesses as cancer, in the treatment of some forms of acute heart failure, and in the control of moderate to severe cough and diarrhoea. Provided by the New South Wales Centre for Education and Information on Drugs and Alcohol. * Registered Trade Name 5 APPENDIX B: MODELS AND EXPLANATIONS OF DRUG USE Adele Stevens Introduction This working paper reviews the explanations and models that have been used to explain why people use psychotrophic drugs in both a problematic and non-problematic manner. The aim of this paper is not to comprehensively review and analyse the models and explanations of drug use but to review some competing theories which may be helpful in understanding present discourses in drug use and treatment. The implications of these models for conducting a trial of controlled availability of opioids will be discussed. As this paper contains a review of past theories of drug use and drug dependence, I have chosen to remain with the terminology of the period where appropriate. Therefore, at times I use the terms 'addict' and 'addiction' (rather than the presently accepted terms of dependency). Theories of Drug Use Theories of addiction and drug use are a relatively recent development coming into prominence mainly in the 20th century. 1. The disease model of addiction The disease model of addiction was developed, especially in relation to alcohol use, in the 1930s and 1940s and was part of the rise of medicalisation in a variety of health and social welfare fields (Edwards 1988:160-169). Prior to this, alcoholism was regarded as immoral, and the alcoholic or drug user as a reprobate. This view was reflected in the Temperance Movement where alcohol generally was seen as evil, and among some groups people were encouraged to take the 'pledge' - to abstain from alcohol. According to the disease model of addiction, addicts are sick; mentally, physically, or both (Riley and Marden 1946). Thus they deserve help, not condemnation for their addiction. Jellinek (1946) is widely credited with developing the disease concept of alcoholism. He described various phases in the drinking history of the alcoholic, two of which he labelled as a disease (Jellinek 1960). Although Jellinek clearly developed a scientific analysis to explain alcoholism, thus giving credence to the disease model, the concept of alcoholism as a disease began much earlier (McAllister, Moore and Makkai 1991 forthcoming:2). In 1890, for example, William Booth; founder of the Salvation Army, supported the concept of the 'disease' of drunkenness and affirmed the need 'to bear upon it every agency, hygienic or otherwise, calculated to effect a cure' (Booth quoted in Drew 1986). Levine argues that the notion that 'alcoholism is a progressive diseaseÉwhose only remedy is abstinenceÉis about 175 or 200 years old, but no older' (1978:143). In the 17th century and for most of the 18th century, 'habitual drunkenness was regarded as natural and normal - as a choice made for pleasure". Liquor was a normal part of living; a food, medicine and social lubricant. According to the writings of the 17th century, people drank and got drunk because they wanted to and because they loved to drink, not because they 'had' to or could not help it. By the 19th century, Levine argues, the notion of drunkenness as due to an overwhelming and irresistible desire for liquor was beginning to develop and was a 'major strand of 19th century thought - the ideology of the Temperance Movement' (1978:144). The Temperance Movement located the source of the addiction in the drug (alcohol) whereas in the post-Prohibition era the source of the addiction was located in the individual body - the 'new disease concept". This represented a development in thought about addiction but, Levine argues, it was 'still well within the paradigm first established by the Temperance Movement". Citing various authors Drew, then Senior Medical Adviser for the Drugs of Dependence Branch of the Commonwealth Department of Health, summarised the factors he saw as associated with the development of the disease model in this century: 6 'The disease concept, as it applied to a self-destructive drinking pattern, was introduced as a reaction to overt moral condemnation or sheer neglect and indifference (Watts 1981), to inspire the hope of effective treatment (Marwick 1984), to avoid guilt, shame and stigmatization (Tournier 1985) and to justify attempts at constructive intervention. It authenticated drug use as a medical problem, and stimulated scientific enquiry into the etiology and treatment methods (including their evaluation)."(1986:264) The concept of addiction as a disease proved useful for two groups. For those with a drug problem, labelling addiction and alcoholism as a disease removed much of the responsibility and moral condemnation for their drug problem. For the clinical staff, it created a branch of medicine with a scientific base thus producing a recognised medical speciality. The disease model, however, has some negative trade-offs for the person with a drug problem. By accepting the sick role entailed in the disease model, the individuals hand over some control and responsibility for their lives to clinical staff. 'Sick' people can no longer be blamed for their drug problem but the responsibility is shifted to the health professional. The addict has the responsibility to seek and cooperate in treatment but 'he or she does not have to get well' (Krivanek 1988:204 - emphasis in the original). The concept of the 'sick role' was formulated by Parsons in the 1950s. Segall (1976), in a review of Parson's theory, states that the sick role entails a loss of social control in that individuals who accept the sick role receive dispensation from ordinary social responsibilities, conditional upon them conforming to a set of appropriate norms of behaviour including co-operation and seeking professional help. For many drug users, there are inherent problems in accepting the sick role. The vacillation between co-operation and aggression which is seen in some methadone clinic patients may be a demonstration of this conflict. Amongst the treatment and research fraternity, the problems inherent in the disease model have increasingly been recognised over the last twenty years. The disease concept has been criticised and there have been a number of attempts at modifying or overthrowing it (Drew 1986). The principal change has been the development of the view that 'the abnormality involves both a biological component and aberrant learning' (Edwards and Gross 1976), which has lead to a psychosocial approach (Saleeby 1985) for treatment. Alexander (1987) suggests replacing the disease model with an adaptive model which conceptualises addiction as a way of coping. According to the adaptive model, addiction results from adaptation to a faulty environment; either faulty upbringing, environmental inadequacy, and/or genetic unfitness. Although Alexander alters the analysis of the disease model to include social factors, he still conceptualises the drug user as a person with a problem, at odds with society. The problems associated with the disease model have been a source of debate among the drug experts at the World Health Organisation for the last two decades (Whitelock 1980; Drew 1986). In 1980, the World Health Organisation officially recommended abandoning the term 'addiction' (Drew 1986; Edwards, Arif and Hodgson 1982), and replacing it with the concept of 'drug dependence'. Despite all these difficulties, the disease model persists and still holds an important place in underpining the treatment practices of many alcohol and drug treatment services (O'Malley and Mugford forthcoming; Krivanek 1988). Overtones of moralism remain. For example, a survey of drug and alcohol program professionals in the 1980s in the US found that 'most alcohol and drug program workers still believe that alcoholics are in some fashion responsible for their plight and (inferentially) can somehow will themselves to recovery' (Tournier 1985:45). The predominant view is, however, that people with a drug problem are sick in some way, either physically (such as the Alcoholics Anonymous view of alcoholism as a disease) or psychologically due to either 'faulty' upbringing or 'faulty' adaptation to their environment. This latter theorising is somewhat in accord with behavioural models for treating drug problems. Behavioural approaches to treatment incorporate social and cognitive learning. This approach is moving away from the disease model which sees excessive drug-taking and drinking as largely uncontrolled (and therefore requiring abstinence as part of the cure) to an approach which recognises the influence of cognitive and social learning factors in changing behaviour (Heather, Batey, Saunders and Wodak 1989). This approach, nevertheless, remains within the pathology paradigm, being concerned with people who have a problem with their drug use and providing treatment within a clinical setting. 2. The moral model Krivanek (1988) uses a moral model to explain a number of other approaches to illegal drug use. Moral positions on addictions have been around for a long time and Krivanek argues that the classical notion of 'man, knowing good and evil, must be held responsible (and must be punished , whether by God or the community) for acts performed with a guilty state of mind has persisted in the criminal laws governing major offences' (206-207). 7 These concepts of moral responsibility form the basis for moral models such as the enforcement model and the preventative model. 2.1 The enforcement model The enforcement model assumes the moral weakness of human beings. The law acts as a deterrent against those using illegal drugs, not only against addicts but also those who might become addicts. Those who 'are found guilty of violating the drug laws' are justly punished. The assumption is that addicts will know they have done the wrong thing and refrain in future, if the punishment is severe enough (Krivanek 1988:209). Because humans are weak and can not resist the temptation to do wrong, that is use and supply illegal drugs, the police and the legal system are charged with the responsibility for removing the drug problem (McAllister, Moore and Makkai 1991). This model has been the predominant means of controlling illegal drug use in the United States since the Harrison Act of 1914. 2.2 The preventive model The preventive model is also based on a moral philosophy (Krivanek 1988). In this model, 'drug addiction represents faulty moral education. Young people experiment with drugs because they have not been properly informed about the evils of drugs, or instructed in the seriousness and immorality of drug taking'(1988:209). Thus the solution to problematic drug use is in the community - with families, schools and other education sources. 2.3 An internal values model of addiction Peele (1988) presents a different analysis of the place of moral values in controlling addiction. He sees people's personal values as holding an important place in explaining why some people control a tendency to addiction (both to drugs and to food) and why others do not. However, he tends to locate the source of control more to internal moral values than to an external force. He recognises the place of social forces for individuals in creating their moral values such as occurs in certain societies such as Jewish or Chinese communities. He argues that the disease model has been counter-productive in helping problem users because it negates the role of the individual's moral values in taking control of their addiction. This approach rejects the biological determinant explanation of addiction and uses a moral analysis to explain why many people give up problematic drug use without the use of treatment services. 3. The pleasure model A quite different model explaining drug use is presented by O'Malley and Mugford (forthcoming). This model recognises that the use of psychotrophic drugs for non-medical purposes has been known since human societies were formed (Plant 1981; Siegel 1989). Furthermore, the majority of drug users, of both alcohol and illegal drugs, use their drug of choice without developing problems (Plant 1981:157; Hartnoll et al. 1985; Kosel and Adams 1986; Mugford 1991b). It has been argued, first by Plant (1981) and later by Mugford that models of drug use such as have been described in the previous sections were developed by researchers and health professionals working with people who experienced problematic drug use. These models, which Mugford refers to as deficit models, have been developed by explaining drug use among a minority of the drug using population, that is those with problems with their drug use who come to official attention, either through the health or law enforcement system. The majority of drug users, those who exhibit no pathology associated with their drug use, are ignored by the deficit models (Mugford 1991b). Although psychotrophic drug use for recreational and religious purposes has been present for many centuries, there has been an increase in the level of drug use in the twentieth century. A variety of explanations have been presented for this change. Merton (1963) argues that people have felt the need to retreat from the complexities of modern society through the use of drugs. Mugford, however, argues that the increase in drug use is related to the increase in leisure time in modern capitalist society. With the development of a capitalist mode of production, time has come to be distinctly divided between paid work and leisure whereas there was not this clear distinction in the pre-industrial agricultural system (Mugford and Cohen 1988). Hence, modern society has come to contain 'a complex and possibly contradictory relationship between the production centred ethic which constructs the self through discipline, control, work, 'clock time', deferred gratification and calculative rationality, and a consumption ethic that encourages self expression, leisure, consumer goods and pleasure."(Mugford and Cohen 1988) Increased leisure time has resulted in an increase in the use of pleasurable commodities. Drugs, linked to this trend, need to be thought of as one such commodity. The discourse of pleasure in relation to drugs is common among users. 8 But it has been 'systematically silenced by the pathology discourse, which ignores the idea of pleasure and, or treats it as part of the problem (only weak people seek such pleasures)' (O'Malley and Mugford forthcoming). The pleasure model provides an explanation for a great deal of the recreational drug use, both legal and illegal which occurs at parties and other pleasure related activities. Drugs, including alcohol and coffee, provide rapid transitions in mood states that parallel and 'symbolise the rapid transitions between work and leisure, production and commodities' (O'Malley and Mugford forthcoming). This model, however, does not deny the reality of dependent use. Rather, it recognises that treatment samples of users constitute the minority of users and it sets out to develop a model of drug use for the majority. Clearly, many models may be needed to reflect the differences in populations (McAllister, Moore and Makkai 1991:3). Conclusion Where do these models lead us? Clearly the disease model, even in its adapted forms, is concerned with approaches to treatment. Drug use is seen within a pathology paradigm requiring care and direction to cure problematic drug use. At least to some degree, responsibility for getting well is transferred to others: to clinicans or, for Alcoholics Anonymous or Narcotics Anonymous members, to a higher power. For some people, this loss of control may be self defeating in that it may negate their responsibility for their drug problem (Krivanek 1988; Peele 1988). The enforcement model assumes that the law is needed to act as a deterrent (external control) to discourage and prevent dangerous drug use. External controls are necessary because of human weakness and immorality. Peele, on the other hand, draws attention to the role of internal moral values in controlling problematic drug use. In this model, moral values are internalised and are not imposed as in the enforcement model. They are shaped by the social milieu - culture, class and family. Individuals influenced by these moral values decide at certain periods of their lives, to control their drug use, thus explaining the large numbers of people who give up or control their drug use without using a treatment service. Peele's moral model has much in common with behaviourist models of cognitive social learning. In both cases, some control is vested with the drug user and cognition and social learning are important factors in changing behaviour patterns. Both models deal with problematic drug use. The pleasure model, however, is concerned with explaining non-problematic drug use. Most people use both illegal and legal drugs without getting into trouble and this model implies that treatment and enforcement are not necessary for this group. People use drugs as part of their leisure activities for fun and pleasure and this activity does not impinge on the other parts of their life, particularly if they have a meaningful work and social life. This model has not been well developed because, those who support it argue, clinicans and researcher deal almost exclusively with people with problematic drug use. For this reason the pathology models dominate in the drug field. They only deal, however, with a minority of the drug using population. The pleasure model attempts to explain drug use among the majority, those with non-problematic patterns of drug use. It does not deny the realities of drug dependence and problematic use but it does argue that we need more than the pathology models to explain the diversity of drug use in the community. References Alexander B.F. 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(1991a) Heroin policy and deficit models. Crime, Law and Social Change 15: 19-36. Mugford S. (1991b) Controlled drug use among recreational users: sociological perspectives. in W. Miller et al. (eds) Self Control in the Addictive Behaviours. Pergamon Press (in press). Mugford S. and Cohen P. (1988) Pathology, Pleasure and the State: towards an integrated theory of drug use. Paper presented at the 1988 Annual Conference of the Australian and New Zealand Society of Criminology, Sydney. Peele S. (1988) Visions of Addiction. Lexington Books, Lexington. Plant M.A. (1981) Drugs in Perspective. Hodder and Stoughton, London. Riley J.W. and Marden C.F. (1946) The medical profession and the problem of alcoholism. Quarterly Journal of Studies on Alcohol 7(2): 240-270. Saleebey D. (1985) A social psychological perspective on addiction: themes and disharmonies. Journal of Drug Issues 15(1): 17-28. Segall A. (1976) The sick role concept: understanding illness behaviour. Journal of Health and Social Behavior 17: 162-168. Siegel R.K. (1989) Intoxication: Life in Pursuit of Artificial Paradise. Simon & Schuster, London. Tournier R.E. (1985) The medicalization of alcoholism: discontinuities in ideologies of deviance. Journal of Drug Issues 15(1): 39-49. Whitelock F.A. (1980) Drugs: drinking and recreational drug use in Australia. Australia, Cassell. 10 APPENDIX C: QUESTIONNAIRE ON POSSIBLE OPTIONS FOR A TRIAL Questionnaire for Reference Group on Possible Options for a Trial Preamble: You will be aware that the Legislative Assembly of the ACT has set up a Select Committee on HIV, illegal Drugs and Prostitution, chaired by Michael Moore. Among other things, this committee is considering ways to minimise harm arising from illegal drug use. One possibility is to do something about the availability of illegal drugs. It has been proposed that there should be a trial in the ACT where opiates* are made available to users through other than illegal channels. We are currently investigating whether or not such a trial would be feasible and we are looking particularly at: what such a trial should look like, what the legal and ethical issues are, what community and key stakeholder attitudes are, and how we could determine if such a trial in fact reduced harm. We are currently obtaining comments by interview or questionnaire from a range of key informants about the first of these, namely what a trial should look like. ***** If opiates were to be made available to illicit drug users in a trial program in Canberra, how would you like to see such a program run? It would also be useful if you would comment on ways you think the program should not be run. Please comment specifically on the following issues and, if possible, give reasons for your comments: 1. Which opiates (heroin, morphine, methadone) should be made available and which routes of administration (injectable, oral, smokeable, snortable) should be made possible? 2. What should be the characteristics of the users who participate in the trial (e.g. dependent users only, people who use heroin as their primary drug only, people not currently in a treatment program)? 3. What should the distribution point(s) be (e.g. health care centre, mobile bus)? 4. Where should the distribution point(s) be (considering particularly accessibility and driving under the influence)? 5. When should the distribution points be open? 6. Who should staff the distribution points? ______________________________ *The term 'opiates' is incorrectly used throughout. The correct term is 'opioids' (see Appendix A). However the subtleties of the difference are unlikely to have misled the respondents.