Terra Sigillata

. . .that’s the message from Dr Bertha Madras, deputy director of the White House Office on National Drug Control Policy, to heroin and morphine users whose lives might be saved in the overdose situation by public distribution of “overdose rescue kits” comprised of a $9.50 nasal spray containing Narcan.

Narcan is the brand name for naloxone, an antagonist (blocker) of these drugs at μ opioid receptors. When an overdose of opioid drugs binds to these receptors in the respiratory control center of a primitive part of our brain, one stops breathing, a situation that pathologists say is “incompatible with life.” Naloxone is ineffective when taken orally because it is metabolized too quickly and, even if it wasn’t, wouldn’t reach the brain in time to compete with heroin/morphine binding to these receptors. But when administered in a nasal spray, Narcan 1) bypasses metabolism by the liver and 2) gets to the brain much more rapidly.

Since being distributed in 16 communities the overdose-rescue kits have saved 2600 lives, nearly the number of people who perished in the combined terrorist attacks of 11 Sept 2001.

James Hrynyshyn at the Island of Doubt reminds us that this story, currently making the rounds of the blogosphere, first aired on NPR on 2 Jan. This story was originally brought to my attention by Dr Tom Levenson who writes the excellent blog, The Inverse Square (there’s a reason he is a MIT full professor of science writing and author of several books). I believe that Mark Kleiman of The Reality-Based Community is responsible for starting this latest round of complete and utter disbelief of the hypocritical “compassionate conservatives” currently occupying positions of power over US public health policy.

The money quotes from Dr Madras are as follows:

“First of all, I don’t agree with giving an opioid antidote to non-medical professionals. That’s No. 1,” she says. “I just don’t think that’s good public health policy.”

Madras says drug users aren’t likely to be competent to deal with an overdose emergency. More importantly, she says, Narcan kits may actually encourage drug abusers to keep using heroin because they know overdosing isn’t as likely.

Madras says the rescue programs might take away the drug user’s motivation to get into detoxification and drug treatment.

“Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services,” Madras says.

As the inimitable Dr PZ Myers then mused on how the administration might extend this compassion:

Hey, here’s another suggestion: let’s stop teaching people the Heimlich maneuver. Not only does it put a medical procedure in the hands of mere non-medical professionals, watching a few fat people in your local McDonalds choke and die, turning purple, thrashing on the floor, and clawing their throats, would be an excellent salutary lesson in the dangers of gluttony and poor dietary habits.

The very sad issue associated with this policy is noted by new ScienceBlogs colleague, DrugMonkey, in that Dr Madras is not some tool of the Bush administration; instead, she has had a distinguished career in the trenches as a drug abuse researcher:

The thing that bothers me the most about this is that Dr. Madras knows better. This is not some political hack or think-tank reject. This is a long time drug abuse researcher. If you read what she had to say closely you will note that she was trying to find the path that did the least insult to the available science. It was all about trying to justify on the basis of an opinion (read “political position”) that had the least possible chance of getting attacked on scientific grounds. Very deft, Dr. Madras!

The takehome is that getting scientists into even quite senior positions is insufficient. Because they obviously get themselves into positions in which they are forced to prioritize the political over the scientific.

Epidemiologist Dr Tara Smith gives her take from a public health policy perspective:

I don’t doubt that this “scared straight” effect works for some drug addicts, but it’s absurd to base a public health policy on something so unlikely. This is much like the uproar over needle exchange programs–they’d been shown to work, shown to reduce the spread of disease and to save lives, but many conservatives opposed them because they “encouraged” or somehow gave validation to injection drug use as a lifestyle; or like arguing to withhold the HPV vaccine for fear of increasing promiscuity.

We return to James Hrynyshyn who follows up on Tara’s point in discussing how the ends do justify the means:

Please. As any honest ethicist will tell you, sometime the means are justified. Sometime they don’t, but often they can. The case of abortion is a perfect example. If you want to reduce the number of unwanted children, and therefore the demand for abortion, then the best way is to make sure everyone has ready access to contraception. And because the demand for abortion is unaffected by the laws governing the procedure, the best way to reduce the maternal mortality associated with the process is to make it legal and easy to procure.

The bottom line is that public health policy should be defined by experts in public health, independently of any political influence or alliance with a party line. Drug abuse is an extensive problem in the US and evidence has accumulated that much of the propensity toward substance abuse is genetically determined; of all the experimenting with drugs that occurs on college campus, only a small fraction of those go on to abuse drugs in their later adult years. Treatment and rehabilitation are two of the answers. Look around you: you are certain to have family members, co-workers, and/or other people you love who are substance abusers and deserving of help.

In prohibiting the distribution of the Narcan kits, Mike the Mad Biologist noted succinctly,

And desperate people won’t get the help they need to stay alive.

*the title of this post pays homage to Steve Martin on his 1978 “A Wild and Crazy Guy” album (Warner Bros, HS3238) in a monologue about his failed attempts writing cheers for his high school – yes, I still have my own original copy of this record.

Comments

#1 NJ
January 29, 2008

Try and make a touchdown, you scumbags!

I replaced my vinyl copy with a CD, and the contents now reside on my iPod.
#2 Tom Levenson
January 29, 2008

Thanks for this post. One very minor correction: no doctor, me.
Other than that — here’s the issue assembled into a single coherent structure. Good stuff.

Tom (aka Inverse Square)
#3 such.ire
January 29, 2008

I’m more on the side of all of you advocating protecting drug users and such, for reasons of compassion and decent human empathy, but I also do think that such programs do encourage drug use (though the effect may be small). It’s simple supply and demand; if you lower the cost (i.e. lower some of the risk associated with drugs), you increase the demand. Undoubtedly, more people went skydiving once having a backup parachute became standard, because there was less risk involved. In the same way, I think more people would use drugs because of programs like needle exchange, distributing drug overdose kits, and such, though I think the effect is probably pretty small, considering the other, dominant cost of taking drugs (expense, addiction, brain and health damage, etc.).

Those negative side effects of the programs, though, are pretty slim compared to their value in saving lives, making room in a crowded medical system for other people to use emergency services and whatnot. So, I guess I agree with both sides, to a certain extent; it’s just that I think the balance is tipped in your favor, simply due to the worth of a human life.

One could also ask how far one should go in helping drug users stay clear of risks; if one is going to supply clean needles and tools for using drugs, what about the risk of using contaminated drugs, which is surely non-negligible? Wouldn’t there be some public health benefit to supplying addicts with clean, government inspected drugs? There would obviously be bad consequences to such a program, ones which may outweigh the good benefits, and (alas) the decision for my support would ultimately come down to the hard calculus of human lives.
#4 Brian
January 29, 2008

Narcan ain’t exactly a walk in the park, either. Never met anyone who enjoyed the experience of acute withdrawal, complete with nausea, diarrhea, tremors, etc.
#5 milkshake
January 29, 2008

In the spirit of post-9/11 amendments of the 4th amendmend I would sell the Narkan sprays cheaply in vending machines. Each spray would be equipped by a remotely-activable radiofrequency homing beacon that would also sound whenever the spray would be used.
#6 Ian Musgrave
January 29, 2008

Such Ire wrote

but I also do think that such programs do encourage drug use … I think more people would use drugs because of programs like needle exchange, distributing drug overdose kits, and such, though I think the effect is probably pretty small,

In fact all the evidence shows that needle exchange and similar programs do not encourage drug use and send more people into treatment programs (in Australia drug treatment rose from 68% to 75% after needle exchanges became prevalent, and injecting drug use fell from 0.6% to 0.4%). Along with reduction of HIV infection, Hepatitis C infection, reduction in drug use litter and increases in public order, as well as significant reductions in public health costs, needle exchange is a major positive step in dealing with injectable drug abuse.

Given that needle exchange programs do not encourage drug use, it is hard to see how Narcan rescue kits would encourage drug use (overdose will still be horrible, just less likely to be lethal). The rejection of a kit that can save lives without any evidence that there are significant harms associated with its use is reprehensible.

See:
Dolan, K, et al. (2005) Needle and Syringe Programs: A Review of the Evidence, Australian Government Department of Health and Aging, Canberra
Needle Exchange Programs (NEPs) FAQs
Harm Reduction: Questions and Answers
#7 Glenn
January 30, 2008

It’s simple supply and demand; if you lower the cost (i.e. lower some of the risk associated with drugs), you increase the demand.

I think any assumption that the normal laws of economics — i.e., that people act in their rational interest — apply to drug users is highly suspect, if not absurd on its face. And I speak from experience. The pull of addiction highly distorts, if not obliterates completely, rational calculus. Only actual evidence, not blithe assumptions, would be acceptable to support the notion that distributing Narcan increases heroin use. And, as Ian points out, the evidence as respects needle-exchange suggests precisely the opposite.
#8 such.ire
February 4, 2008

Supply and demand is as close to a law as you can get in economics; they apply almost universally. Economics also uses a special definition of the word “rational”, in the same way that science uses a special definition of the word “theory.” To economists, “rational” means “preferences are consistent” and “people respond to incentives” (e.g. addicts consistently prefer drugs to, say, good health, and they’ll respond if you offer them more drugs or money). We modeled drug addiction in my microeconomics class quite simply when I took it; there’s no conflict between the behavior of addiction and a the economist’s rational agent.

Just look at the cigarette tax to see supply-and-demand laws at work; higher taxes on cigarettes led to falling sales in cigarettes, if only because fewer people could afford to buy the cigarettes. In the same way, if more people can afford the risk of drugs, more people will use them. Demand curves slope down.

Of course, this negative side effect could be so small that it gets lost in the noise of other, positive side effects of needle exchange programs, such as incentivizing addicts to have more contact with those who can help them out of their addictions, or simply the humanitarian and ethical benefits of keeping people from disease. I’m not saying that we shouldn’t do the needle exchange program; I’m saying that it’s disingenuous to say that the normal laws of economics don’t apply to this situation.
#9 DuWayne
February 4, 2008

such ire -

I’m saying that it’s disingenuous to say that the normal laws of economics don’t apply to this situation.

But they don’t, at least not in simplistic terms. People just don’t look at highly addictive drugs from a perspective that would make it apply. They don’t come at heroin or cocaine with the notion that they would ever have a use for needle exchanges or something that would save them in the event of an overdose. In short, they don’t believe that they will become addicted. If they aren’t addicted, things like needle exchanges and Narcan aren’t going to enter the equation when they decide whether or not to use a highly addictive substance. Once they are addicted, it becomes irrelevant.

Of course, if you aren’t going to let Ian’s actual evidence in the form of study convince you, I doubt this will. But take it from someone who has had a lot of experience with illicit drugs, no one begins using any addictive drug, thinking that they might at some point need a needle exchange or Narcan. They don’t think gosh, since I can use the needle exchange and the Narcan is out there to help me, I think I’ll become a junkie. It just doesn’t happen.