P Clark. Heroin Addiction: An Ethical Evaluation of New York City’s Heroin Manual. The Internet Journal of Health. 2009 Volume 12 Number 1.
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.” 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.[ii] New York Public Health officials have made the availability of heroin and heroin addiction a major focus, but a comprehensive strategy is lacking.
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
The purpose of this article is threefold: first, to present the facts presented in
Take Chare, Take Care
The New York City Department of Health and Mental Hygiene produced and distributed
Prevention of overdose
Treatment of overdose
Don’t share syringes or equipment
Use of new syringes
How to prepare drugs carefully
How to take proper care of your veins
Education on knowing your HIV status through testing
Education on testing and treatment for hepatitis
How to seek help for depression
How to find drug treatment programs
These categories of advice aim to prevent overdoses and infections until these individuals can get into recovery programs. The booklet is a simple and valuable tool to reduce the harm associated with heroin overdoses that are the fourth leading cause of early adult deaths in New York City. The information contained in the booklet provides practical life-saving advice about not taking drugs alone in case something goes wrong, the hazards of combining heroin with other drugs such as alcohol and cocaine, how to obtain and Over Dose (OD) rescue kit, education about never sharing needles, how to contact the local needle exchange program, how to prepare the drugs carefully, proper care for veins; referral numbers for HIV and hepatitis testing and treatment, and the local number for Life Net regarding depression and drug treatment centers. If the goal of this booklet is to promote health, reduce harm and save lives, then why has it become so controversial?
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
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
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
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:
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.
The harmful effect must not be the means of producing the good effect.
The harmful effect is sincerely not intended, but merely tolerated.
There must be a proportionate reason for performing the action, in spite of the harmful consequence.
The principle of double effect is applicable to the issue of
Finally, the argument for the ethical justification of
Proportionate reason refers to a specific value and its relation to all elements in the action. 34 The specific value in allowing for
The means used will not cause more harm than necessary to achieve the value.
No less harmful way exists to protect the value.
The means used to achieve the value will not undermine it.
The application of McCormick’s criteria to
The critical aspect that cannot be overlooked in the ten steps offered in
Evidence has shown that