Background and Review

Public health officials are grappling with a new wave of heroin abuse across the New York Region. “During the first six months of 2009, 25 people in Nassau County died of heroin overdoses—more than from homicide and drunk driving combined; in 2008, 46 people fatally overdosed on heroin, up from 27 in 2007, according to Nassau officials. In New York City, recent drug raids of so-called heroin mills yielded hundreds of thousands of bags of drugs at a time, up from several hundred bags a year.” ₁ One of the most alarming aspects of this increase in heroin use is that it is occurring among teens and people in their early 20s; and many come from upper or middle-class suburban families. Another alarming aspect is that the heroin that is available in the Northeast is purer and more lethal than the kind that ravaged New York City in the 1970s. Dealers often mark bags of heroin with words like “Red Bull,” “Lexus,” “Kiss of Death,” “R.I.P” or skull and crossbones. This spike in heroin use is attributed to its widespread availability and low cost. A bag of heroin can sell for $5 to $25 and induce a six- to -eight hour high. Cocaine, by comparison, can cost $40 to $60 for a 30-minute high while prescription pain killers like Vicodin or OxyContin sell more than $40 a pill on the street. ₂ New York Public Health officials have made the availability of heroin and heroin addiction a major focus, but a comprehensive strategy is lacking.

Heroin, also known as diamophorine, is a semi-synthetic opioid drug of the opium poppy. Heroin usually appears as a brown or white powder or a black sticky substance known as “black tar heroin.” ₃ As with other opioids, heroin is used as both a pain-killer and a recreational drug and has a high potential for abuse. Heroin can be injected, snorted/sniffed, or smoked, routes of administration that rapidly deliver the drug to the brain. “Heroin enters the brain, where it is converted to morphine and binds to receptors known as opioid receptors. These receptors are located in many areas of the brain (and in the body), especially those involved in perception of pain and in reward. Opioid receptors are also located in the brain stem—important for automatic processes critical for life, such as breathing (respiration), blood pressure, and arousal. Heroin overdoses frequently involve suppression of respiration.” ₄ Heroin acts as a pro-drug that allows rapid and complete central nervous system absorption; this accounts for the drug’s euphoric and toxic effects. ₅ Regular heroin users develop a tolerance in which the user’s physiological and psychological response to the drug decreases, and additional heroin is needed to achieve the same intensity of effect. Heroin users are at a high risk for addiction. It is estimated that about 23% of individuals who use heroin become dependent on it. ₆ A range of treatments exist for heroin addiction, including medications and behavioral therapies. Treatment usually begins with medically assisted detoxification to help patients withdraw from the drug safely. Medications such as clonidine and buprenorphine can be used to help minimize symptoms of withdrawal. The most effective treatment is behavioral treatment in combination with medication. These are usually delivered in residential or outpatient settings. ₇

Heroin use and addition is a major problem both internationally and nationally. The United Nations estimates that there are more than 50 million users of heroin, cocaine and synthetic drugs. Global users of heroin are estimated at between 15.16 million and 21.13 million people ages 15-64. ₈ According to the 2008 National Survey on Drug Use and Health (NSDUH), approximately 3.8 million Americans aged 12 or older reported trying heroin at least once representing 1.5% of the population aged 12 or older. Approximately 453,000 (0.2%) reported using heroin within the past year and 213,000 (0.1%) reported using it in the past month. The number of current (past month) heroin users aged 12 or older in the United States increased from 153,000 in 2007 to 213,000 in 2008. There were 114,000 first-time users of heroin aged 12 or older in 2008. ₉ In New York City, accidental heroin overdoses is the fourth leading cause of early adult death, claiming more than 600 lives each year. ₁₀ In addition, heroin use, particularly in those who inject the drug, is also responsible for spreading needle-related infectious diseases such as hepatitis and HIV/AIDS.

To address the critical problem of heroin overdoses and the increased spread of hepatitis and HIV/AIDS, the New York City Department of Health and Mental Hygiene in 2007 prepared a 16-page guidebook called Take Charge, Take Care: Ten Tips For Safer Use (NYC.gov website). The purpose of this guidebook, according to representatives of the Department of Health and Mental Hygiene, is “to help people who are injecting drugs reduce the harm associated with this type of drug use until they are able to get into treatment and recovery.” ₁₁ Approximately 70,000 copies of the pamphlet have been produced and distributed at a cost to New York City taxpayers of slightly more than $32,000. ₁₂ Proponents argue that this guidebook can help heroin users avoid health issues and potential inflammation, infection and other problems. More importantly, it could possibly save lives and prevent the spread of needle-related infectious diseases. Opponents argue that the 10-step guidebook could encourage the use of heroin, could deceive users into believing there is a safe way to inject heroin, and could be considered a gross misuse of taxpayers’ money.

The purpose of this article is threefold: first, to present the facts presented in Take Charge, Take Care; second, to examine the arguments for and against the guidebook; and third, to give an ethical analysis of this guidebook as a harm-reduction approach to lessen the negative consequences of heroin use.

Take Chare, Take Care

Arguments For and Against

Accidental overdoses are the fourth leading cause of death of young adults in New York City claiming over 600 lives a year. ₁₈ The arguments for publishing and distributing Take Charge, Take Care are based on the practical presumption that heroin drug use exists and will continue to exist and the booklet offers valuable information for users to better understand and reduce their risk from using heroin. Proponents argue that “many people with substance abuse problems eventually get off drugs, and simple steps can reduce harm to themselves until then.” ₁₉ This harm reduction strategy is aimed not only at the drug users, but also at their sexual partners and children that might result. Heroin abuse not only impacts directly on the user but is also one of the leading causes of HIV/AIDS and hepatitis in the general population of New York City.

Opponents argue that the booklet promotes drug abuse, enables users and potential users and implies there is a safe way to use heroin. Their basic argument is that this is a “how-to guide” for drug use. New York City Councilman Peter F. Vallone, Jr., argues that the booklet is also “a publically funded encouragement of illegal drug use and an indefensible waste of taxpayer money.” ₂₀ Vallone and other critics argue that the $32,000 expended on 70,000 printed booklets would have been better spent on drug education, prevention and treatment. Proponents counter this criticism by arguing that this is the same line of reasoning that has been used for the past two decades by opponents of needle exchange programs, methadone maintenance therapy and, more recently, safe-injection facilities. It is also consistent with the federal government’s harm reduction policies and promotion of use reduction in its own approach to drug problems. Opponents fear that “harm reduction is a Trojan horse for the drug legalization movement. Another factor might be that whereas harm reduction focuses on harms to users, drug-related violence and other harms to nonusers are more salient in the United States than in Europe.” ₂₁

In 1997, after an extensive review of available data, the National Institutes of Health concluded that not only did needle exchange programs fail to promote drug use or encourage non-users to use; but they also dramatically reduced rates of HIV transmission all in a cost effective manner. ₂₂ Despite these facts, the federal government still refuses to federally fund needle exchange programs. If the best scientific minds in this country at the National Institutes of Health, the Centers for Disease Control and Prevention, the American Medical Association and the Pharmaceutical Association of America argue that this harm reduction strategy reduces death in our country, then it makes sense to listen and respond accordingly. Proponents believe that Take Charge, Take Care can be compared with needle exchange programs as a harm reduction model. Even though there is no comparable database on the effects of this new initiative, science suggests that the benefits outweigh the potential costs. From 2006-2008, when Take Charge, Take Care was most widely available, rates of unintentional drug overdose declined 25% and HIV infections among injection drug users declined 80% in New York City. ₂₃ Saving this number of lives and preventing this number of HIV infections is clearly beneficial and cost effective. Finally, from a purely practical perspective, Daniel Raymond, policy director for the New York-based Harm Reduction Coalition, argues that “nobody ever started to use drugs because they picked up a pamphlet.” ₂₄ The logic of this argument is compelling.

Proponents also counter arguments against this form of harm reduction by stating clearly that there are many heroin users in New York City, and despite their drug addiction, they are human persons and deserve to be treated with dignity and respect. One way to do this is to reduce the harm of drug addiction until treatment is sought. To say that the booklet only promotes and enables drug abuse is a clear misrepresentation. The 10 steps provide valuable information on ways of treating depression; protecting the user and others from needle-related infectious diseases; and on ways to locate drug treatment centers and obtain replacement therapy. In addition, the guidebooks were not distributed to random members of the New York community, the information on how to inject heroin is aimed at those who are already using the drug heavily. ₂₅ Research studies have shown that providing these tips on safer injection does not appear to encourage non-users to take up the drug habit. The rate of life time heroin use among New York City high school students slightly decreased from 2005 to 2007, from 1.8% to 1.3%. ₂₆ This data is consistent with other research indicating when medical authorities provide means of safer injection drug use, it is the high-risk, long-term users—and not the uninitiated who respond. ₂₇ In regards to the criticism about the booklet being a “how-to-guide” on the “safe use of drugs,” city health officials state that ‘the brochure was aimed at making intravenous drug use ‘safer,’ not ‘safe.” The purpose of this information is to help lessen risks and to save lives. Health Department officials noted that the first page of the booklet urges users to ‘get help and support to stop using drugs’ and that the pamphlet offers 24-hour hotline numbers for them to call.” ₂₈ City officials are very clear that there is no safe way to use heroin. The focus of the booklet, as a harm reduction approach, is pragmatic. The sole desire is not to eliminate drugs or drug use but rather to assist individuals in learning how to live safely and healthfully in a world where drug is a reality. The goal is to provide potentially life-saving advice for these individuals until they seek treatment.

Despite the positive aspects of this harm reduction approach, we may never be able to ascertain the data to determine if Take Charge, Take Care promotes health and saves lives. In response to the recent criticism, the Department of Health and Mental Hygiene removed the guide from its website, and City Councilman Peter Vallone is currently attempting to cut off funding for the booklet’s distribution. If Vallone succeeds so too will “data-proof” decision making. ₂₉ To strengthen the argument for this harm reduction approach, it must be determined whether access to Take Charge, Take Care would promote more good than harm not only for heroin users but also for their associates and the community at large.

Ethical Analysis

Society, in general, has always recognizes that in our complex world there are times when we are faced with situations that have two consequences--one good and the other evil. The time-honored ethical principle that has been applied in these situations is called the principle of double effect. As the name itself implies, the human action has two distinct effects. One effect is intended and good; the other is unintended and harmful. As an ethical principle, it was never intended to be an inflexible rule or a mathematical formula, but rather it is to be used as an efficient guide to prudent moral judgment in solving difficult moral dilemmas. ₃₀ This principle focuses on the agent in terms of intentions and accountability, not just contingent consequences. The principle of double effect specifies four conditions which must be fulfilled for an action with both a good and an evil effect to be ethically justified:

1. The action, considered by itself and independently of its effects, must not be morally harmful. The object of the action must be good or indifferent.

2. The harmful effect must not be the means of producing the good effect.

3. The harmful effect is sincerely not intended, but merely tolerated.

4. There must be a proportionate reason for performing the action, in spite of the harmful consequence. 31

The principle of double effect is applicable to the issue of Take Charge, Take Care because it has two effects, one good and the other bad. The good effect is that this program has the potential to save lives and to reduce the spread of infectious diseases like hepatitis and HIV/AIDS associated with sharing needles. The harmful effect is that some believe that it may send a wrong message that illegal drug use is condoned and even encouraged. To determine if Take Charge, Take Care is ethical, this issue will be examined in light of the four conditions of the principle of double effect.

The first condition allows for Take Charge, Take Care because the object of the action, in and of itself, is good. The moral object is the precise good that is freely willed in this action. The moral object of this action is to save lives by emphasizing treatment and to stop the spread of HIV/AIDS and other infections to intravenous drug users, and subsequently to their sexual partners and potential offspring. The immediate goal is not to endorse illegal drug use or to encourage it. Rather, the direct goal is to teach people to live safely and healthfully and to stop the spread of infectious diseases that could be lethal among a group of individuals who are addicted to illegal drugs and who are either unwilling or unable to seek drug treatment. New York Mayor Michael Bloomberg made this very clear when he stated, “Using hard drugs is just not a smart thing to do. But we have an obligation no matter what people do in this city to make sure they do it as safe as they can.” ₃₂

The second condition permits publication and distribution of this booklet because the good effect of saving lives from overdose and stopping the transmission of HIV and hepatitis to addicts, their sexual partners and offspring is not produced by means of the harmful effect. The two effects are completely independent. Take Charge, Take Care has no intention of encouraging drug abuse. In fact, the opposite is true. To argue that public health officials are encouraging or condoning drug abuse is illogical.

The third condition is met because the direct intention of Take Charge, Take Care is to protect and preserve human life and to encourage drug rehabilitation, social support, professional counseling and medical care. Studies have shown that HIV and hepatitis infection has increased among minority populations especially for those between the ages of 13 and 24 and the majority of these infections are the result of intravenous drug use. The direct intention of this program is to preserve the lives of the most vulnerable that is, the poor and the minorities, by stopping heroin overdoses and the spread of HIV and hepatitis transmission. The foreseen but unintended consequence of this may be the belief by some that this is condoning and even encouraging illegal drug use. Nevertheless, scientific studies from Kerr et al. and Wood et al. support the claim that drug use does not increase among users and that this program does not promote new drug use. ₃₃

Finally, the argument for the ethical justification of Take Charge, Take Care by the principle of double effect focuses on the fourth condition of whether there is a proportionately grave reason for allowing the unintended possibility of scandal and the possibility of increased drug usage. Proportionate reason is the linchpin that holds this complex moral principle together.

Proportionate reason refers to a specific value and its relation to all elements in the action. ₃₄ The specific value in allowing for Take Charge, Take Care is to preserve human life by preventing drug overdoses and preventing the transmission of HIV and hepatitis to the most vulnerable. The harm, which may come about by trying to achieve this value, is the foreseen but unintended possibility that some may view this as condoning and even encouraging illegal drug use. The ethical question is whether the value of preserving human life outweighs the harm of the foreseen, but unintended, possibility of scandal and possible increased drug usage? To determine if a proper relationship exists between the specific value and the other elements of the act, ethicist Richard McCormick, S.J. proposes three criteria for the establishment of proportionate reason:

1. The means used will not cause more harm than necessary to achieve the value.

2. No less harmful way exists to protect the value.

3. The means used to achieve the value will not undermine it. 35

The application of McCormick’s criteria to Take Charge, Take Care supports the argument that there is a proportionate reason for allowing this program. First, scientific data has proven that this booklet, as part of a comprehensive drug prevention program, decreases overdose deaths and decreases HIV and hepatitis infections among injection drug users. The New York Department of Health and Mental Hygiene reports that overdose deaths have declined 25% from 2006 to 2008, representing at least 200 fewer deaths. ₃₆ Statistics have also shown that one-third of Americans infected with HIV have been infected through injection-drug use. According to Jessica Scaperotti, spokesperson for Department of Health and Mental Hygiene, needle exchange programs, like those promoted in the booklet, have been operating in New York City since 1992 and such programs have reduced HIV prevalence among injection-drug users by more than 75%, with hepatitis C infections falling by a third. ₃₇ If this booklet, as part of a comprehensive program, saves lives and reduces HIV and hepatitis transmission and does not increase drug usage or condone drug use, then, this program does not cause more harm than necessary. To verify these facts, the program must continue in order to collect the appropriate data.

Second, at present, there does not appear to be an alternative that is as effective as Taking Charge, Taking Care. It is true that other means exist such as drug treatment and prevention efforts and safer-sex education programs, but according to the most reliable public health and medical sources, the ten tips offered in this booklet are the best means presently available for reducing overdose deaths, and preventing HIV and hepatitis transmission thus saving lives among intravenous drug users. ₃₈ Most experts contend that few drug addicts, especially those within the 13-24 age range, will take advantage of drug treatment programs and educational resources on their own, because their addictive behavior stands in the way.

The critical aspect that cannot be overlooked in the ten steps offered in Take Charge, Take Care is the element of human contact. Human contact is offered though information about medical services for HIV and hepatitis, needle exchange programs, mental health counselors and drug treatment programs. This human contact allows outreach workers to form personal relationships with the addicts and thus provide the opportunity to offer them appropriate health care, personal counseling and referrals to treatment centers. Various scientific studies have confirmed that intravenous drug users reduce risk-laden behaviors when pertinent information and services, such as counseling are made available, and especially when they are offered by peers who are members of the drug-using subcultures. ₃₉ “The human contact and protection from disease that these programs offer communicates a powerful message to addicts that their lives and well-being are still valued by the community, even though they may not yet be able to break the cycle of addictive behavior.” ₄₀ The information contained in this booklet not only has the potential to protect human lives but also to foster human dignity and respect.

Third, Take Charge, Take Care does not undermine the value of human life. One can argue convincingly that the intention of this booklet is to save human lives. This program has the potential to decrease drug overdoses and to prevent the transmission of HIV and other diseases like hepatitis A, B and C and prevent the secondary transmission of HIV to sexual partners and infants. The purpose of this booklet is to save lives and from the current data it appears to be quite effective. This is a public health issue that must be addressed because innocent lives are being lost. It seems clear that there is a proportionate reason to allow for the publication and distribution of Take Charge, Take Care using taxpayer money. This booklet contributes to the well-being of those affected because it preserves their lives and the lives of others by preventing unnecessary overdoes and the transmission of HIV and hepatitis. It also offers those addicted the opportunity to realize that they are valued as persons and that with the appropriate assistance addiction can be overcome. Therefore, it is ethically justified under the principle of double effect to allow for the publication and distribution of Take Charge, Take Care in New York City. It can also be argued, that like the needle exchange programs, this booklet could become a pilot program for other cities experiencing the same drug related issues as New York City. Ethically, the greater good of addicts and the common good of society are advanced by financially supporting the publication and distribution of Take Charge, Take Care.

Conclusion

Evidence has shown that Take Charge, Take Care is both a necessary and a vital part of a broader comprehensive strategy of the New York Department of Health and Mental Hygiene for preventing unnecessary heroin overdoses and death, as well as preventing HIV and hepatitis transmission among intravenous drug users and their significant others. After reviewing all pertinent medical and public health data it is clear that there is more than sufficient evidence to warrant the continued publication and distribution of this booklet. If 70,000 people have access to this booklet, and as a result they use heroin as safely as possible, then there is a high probability that more good than harm could result. Thousands of lives could be saved if the New York City Council will fund this project and the Department of Health and Mental Hygiene would reactivate it on their website. If we, as a nation, believe that the life of every person is sacred and should be treated with dignity and respect, especially the lives of the most vulnerable, then we must do what we believe the greater good directs to protect and preserve human life. This does not mean that we should not continue to explore, test, and develop other approaches to heroin drug addiction. A comprehensive strategy that includes a prevention strategy, a treatment strategy and a harm reduction strategy could serve as a new paradigm to guide our decisions regarding drug addiction. If this spectrum of approaches is the best method available at the present time to protect the lives of drug users, their sexual partners and offspring, then society must utilize it to its fullest capacity. However, it appears that the New York Department of Health and Mental Hygiene by removing this booklet from its website has put politics and appearances ahead of science and public health considerations. We cannot allow the appearance of scandal or the fear that the New York City Council might be accused of being soft on drugs to stand in the way of proven scientific evidence. Human lives are hanging in the balance. If the protection and preservation of human life is a priority, then the New York City Department of Health and Mental Hygiene must reverse their position before it is too late for those who are the most vulnerable.