Welcome to Issue 6 of Junkmail, Australia’s only national maga-zine produced entirely by drug users for drug users. You may have noticed from the cover that this issue has an international

flavour.

The articles in this issue focus on some of the struggles for existence and recognition of human rights and dignity that drug users are currently fighting around the world. We have tried to give you a picture of what it is like to be an illicit drug user in other parts of the world so you can see some of the similarities and differences with the lives of drug users here in Australia.

We hope you enjoy the “International News” section on pp. 12 & 13 to keep you up to date on what’s going on with illicit drugs around the world and the article on the history of Australia’s appraoch to drugs policy on pp. 29 & 32 to bring you up to speed on how our current laws and policies in relation to drugs came about.

Not all of the articles focus on international issues and we have also included important health information on hepatitis C treatments and endocarditis and a summary of some of the latest hep c and drug treatment research in Australia and beyond. As promised, we have also included the regular update on retractable needles & syringes and a summary of the new two-year AIVL Policy Program.

It seems Junkmail is growing in popularity with every issue. We hope that Issue 6 both enlightens and informs but most of all, we hope that Junkmail 6 will leave you feeling part of a global movement for drug user rights - you just have to make the choice to get on board! See ya.

P.S. Hope to see Aussie users at the International Conference

CREDITSEditor: Annie Madden, Co-editor: Nicky BathEditorial Board: Charles Roberts and Paul Gill Thanks to: The rest of the AIVL staff team: Jude Byrne, Dayle Stubbs, Beth Harvey, Skye Jewel for their input. All of the individual drug users and others who have contributed articles and/or graphics to this issue (individual credits are provided with each article and graphic contributed).

Graphic Design: John Carey Arts

Printing: Goanna Printing, CanberraAustralian Injecting & Illicit Drug Users League (AIVL)

Address: Level 2, Sydney Building 112-116 Alinga Street Canberra, ACT 2601.

Postal: GPO Box 1552 Canberra, ACT 2601 AUSTRALIA

Telephone: (02) 6279 1600Facsmile: (02) 6279 1610Email: anniem@aivl.org.au

In the last Issue of Junkmail (Issue 5) we neglected to appropriately credit a graphic provided by Justine Dalziel. Justine’s graphic was used to illustrate the article written by Paul Gill titled Service with Attitude... a true story about rehab and being hep C positive. The graphic which appeared on page 12 is reprinted below. Junkmail sincerely apologises to Justine for this oversight.

APOLOGY FROM ISSUE 5

by Justine Dalziel

DISCLAIMERThe contents of this magazine do not necessarily represent the views of the Australian Injecting & Illicit Drug Users League Inc. (AIVL). AIVL does not judge people who choose to use illicit drugs, and Junkmail welcomes contributions which express opinions and raise issues of concern to people who use or have used illicit drugs. The contents of Junkmail do not encourage anyone to break the law or use illicit drugs. While not intending to censor or change their meaning, Junkmail reserves the right to edit articles for length, grammar and clarity. Junkmail allows credited reprinting by drug user organisations and other community-based groups with prior approval, available by contacting AIVL. Information in this magazine cannot be guaranteed for accuracy by AIVL. AIVL takes no responsibility for any misfortunes which may result from any actions taken based on materials within Junkmail and does not idemnify readers against any harms incurred. The distribution of this publication is targeted - Junkmail is not intended for general distribution.

Editorial & Credits page 2Contents page 3Letters to Junkmail page 4Prison-Based Needle & Syringe Programs Why Don’t We Have Them? page 5NSEP in the Roman Empire page 10International Drugs News page 12Aussie Drugs News page 14International Conference on the Reduction of Drug Related Harm in Melbourne page 15Hepatitis C - Who Cares? page 16Endocarditis - Information Update page 18Chiang Mai and Thailand’s War on Drugs page 21Should People with Hepatitis C who are Currently Injecting Drugs Consider Interferon and Ribavirin Treatment? page 24Retractable Needles & Syringes - Whatsup? page 26A Brief History of Drug Policy in Australia page 29Injecting Methamphetamine? Then PSU is for You! page 33The Global Cirque-de-Userphobia page 35Latest Hep C and Drug Treatment Research Section page 40

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So You Think You’re Bulletproof?

I started using heroin way back in 1985, things were a lot different back then. Needles were a lot harder to get so we all shared and resharpened the needles. But being young and new to it all we thought a lot differently - we thought we were bulletproof.

OD’s and blood borne viruses only happened to other people or, as in many cases, we simply didn’t care. By 1990 however, most of my friends had hep C or were dead. Most of my friends didn’t make it past twenty-five. In 1988, I had fourteen of my friends die. It hit us all hard but never really stopped us as we were bulletproof; they were just unlucky.

I have had a few breaks from it over the years but always return to my old friend heroin. Yeah, I know you have heard it all before and why worry - you’re bulletproof too. But guess what? No-one is bulletproof. And as for lucky, living with blood borne viruses and thinking of all your closest friends who are now dead and friends who are still dying can be really depressing.

I would never try to convince anyone to stop using. I have no plans to stop, but remember if using is the most important thing in your life, you’re not using the drug, the drug is using you. Drug use should be secondary, something you do to compliment your life, not your reason for living.

Just remember you’re not bulletproof. Use, but use safely - you only die once.

Frog

It’s Time to Act!

Hi guys,

I have just finished reading ‘Junkmail’ Issue no. 5 (summer) and I have gotta say it could not have come at a better time! Thank you all who make this possible!

After reading Erin O’Mara’s story I am now left wondering: ”Must you be a British citizen to get on the heroin maintenance program?” Coz as I sit here and work out all the $$$ I have spent on gear (and surprise, surprise, ‘getting well’, which I believe has cost so much more) I find myself getting very angry at the fact that if I seriously want to look at getting well, ‘my way’, I have to change countries! I am currently back on ‘done after doing the whole bup (buprenorphine) round trip and IT F***IN’ SUCKS! Thank God for people like Erin (and yourselves) who continue to try and make our dreams a reality. This article has indeed got my little brain thinking. I am not the most apathetic person but I am realising that if I want change initiated I MUST become PART of that change, by working towards it and not just thinking: “Gee, its OK. Those cool people at AIVL and VIVAIDS are doing their thing on my behalf so I don’t have to do anything except whinge and moan about how I’d like it to be.” WHAT BULLS**T!!!

It’s time to act; NOW. Last year I obtained my ‘Youth Work Certificate IV’ and this year (a whole f***ing year) I have dedicated to getting off the ‘done. Yet, I am realising that ‘getting well’ for me (like a lot of others) entails some form of service work that will help to make an ultimate difference in how a ‘junkie’ is perceived in the future. I

believe for me, this lies in working towards/within some kind of harm minimisation program. I am in country Victoria (near Ballarat where the Bendigo hospital has only four beds for D&A cases and encompasses something like 2,000 km) where I believe more needs to be done towards harm minimisation, as most of us have moved away from the city to gain some kind of ‘independence’ from the system, not specifically coz we all now attend N/A and are relentless in keeping our recovery happening by counting the clean days (*rolls eyes*.... )

Well, this has got a little long winded. So yeah, you’re articles are amazing. (Loved the ‘Heroin Trials’ article, and yes, I will speak to five people in relation to the ‘legalisation of H’. Applause to the author of that piece, very clear, concise and to the point, which is no mean feat when legal jargon abounds, I would think. Thank you.)

Just a HUGE thanks in general... Also, I would like to comment on the methadone article (liquid handcuffs) and possibly get it published. How do I go about that? OK, this time I am outta here...

PEACE ONE LOVE

Michelle... sat nam.

The War on Drug Users?

The Editor,

The Northside Chronicle and the Canberra Times have reached a new high in the lows of corporate sponsored government journalism. In its ‘War on Terror’ (or should it be War of Terror) do they know the terror of being homeless in Australia today? Of your first wet, cold night of waiting until 9.00am to get a cup of coffee for breakfast from a friendly office person?

The Northside Chronicle on Tuesday 14th May 2003 ran a front page colour photo of a young woman with a fit still in her arm who, thanks to the Northside Chronicle, now is someone “WE LIVE IN FEAR” of on a local level. The Canberra Times in its Saturday Forum 24th May 2003 decided to raise the profile of Canberra’s Community Care sector by using the same photo as the Chronicle under the banner “MOST BURGLARIES RAISE MONEY TO BUY HEROIN”.

None of the reporting in the articles have anything much to do with the young woman that they used on their front page and in the Saturday Forum. Drug use today has turned into a form of suicide; if you don’t go to prison, if you are not homeless now, you will be soon. All this as society purges itself of these ‘welfare parasites’; the mentally ill, the drug users, the single mothers, the poor - all those who are not part of the mainstream social fabric of the future of Australia!

Was the Northside Chronicle proud of its efforts? On Tuesday 20th May 2003 the Northside Chronicle followed up with another article using the same photo of the young woman titled: “NEW HOUSE RULES - Tenants Bold New Plan to Maintain Order at their Units”. (This article focussed on eliminating crime and ‘anti-social behaviour’ at Canberra’s public housing blocks highlighting illicit drugs and those who

LETTERS LETTERS

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Some BackgroundFor some time AIVL has been concerned about the gaps in service provision and neglect for the health and human rights of injecting and illicit drug users within the prison system in Australia. Prisoners are a group of people who experience extreme levels of discrimination and marginalisation in society. Australians are routinely led to believe, by the media and other propaganda, that the loss of liberty in itself is not sufficient punishment for those convicted of committing a crime. Headlines bombard the general public often stating that prisoners are able to access fabulous services and programs and some prisons are more like ‘holiday

parks’ than institutions of punishment. It is probably true to say that the average Australian has very limited knowledge of the day to day reality for prisoners - the individual fight for survival in a system that can be both brutal and inhumane. For the prisoner who is also an injecting drug user, there are even more issues to deal with not only to survive but, to protect one’s health.

As is stated in the general principles spelt out in the WHO Guidelines on HIV Infection and AIDS in Prisons:

“All prisoners have the right to receive health care, including preventative measures, equivalent to that available in the community without discrimination, in particular with respect to their legal status and nationality.”1

the past few years there has been quite a lot of discussion about whether there should be Needle and Syringe Programs (NSPs) in Australian prisons. AIVL believes that prisoners should have easy access to clean injecting equipment and other health services for that matter, but we have been feeling increasingly frustrated with the complete lack of action on this issue. So, rather than getting caught up in an endless discus-

sion about ‘whether’ we should have NSPs in prisons, AIVL decided to go ahead and develop a paper about ‘how’ we could make NSPs in prisons a reality. The result is the AIVL Discussion Paper on Prison-Based Syringe Exchange Programs (PSE). This article is a summary of the key issues in the AIVL discussion paper...

AIVL believes that such principles, along with the multitude of other legislation, declarations and charters that strive to protect prisoners’ health, are quite simply being overlooked or worse, being actively ignored by Australian prisons. Prisoners in Australian prisons do not have access to the same level and quality of healthcare as in the general community. This is not a judgment, it is a statement of fact, and something that AIVL believes must be addressed as a matter of urgency.

In addition to blood borne virus transmission, the lack of clean injecting equipment considerably exacerbates the general health and well being of injecting drug users while in prison. Individuals may experience:

• Abscesses;

• Bacterial infections;

• Thrombosis;

• Collapsed veins;

• Endocarditis;

• Tetanus;

• Septicemia.

Due to the incriminating nature of injecting drug use, many individuals suffer in silence while in prison and do not seek treatment. Too often, health problems that are relatively easy to treat if addressed early are left until they become more complex and distressing.

AIVL’s Guiding Principles for PSE ProgramsIn response to the current situation, AIVL decided as part of the policy program of activities to begin to tackle this important issue. AIVL opted to develop a set of guiding principles for PSE programs in prisons to enable us to actively advocate for a trial of PSE programs in Australia. As each prison is different, we chose to devleop a series of principles aimed at increasing debate and discussion rather than to develop a prescriptive model for use in all prison settings.

We also noted that much of the literature on current programs stress the importance of prisons developing models that work for all stakeholders (including injecting drug using prisoners). Programs in operation overseas have highlighted the importance of consultation with all stakeholders and promoting a sense of ownership of the PSE program amongst stakeholders.

We did not believe a single, prescriptive model would provide the flexibility necessary to meet the needs of a diverse range of stakeholders. In addition, AIVL was concerned that a set model could decrease the percieved need to consult with stakeholders and gain their support. In contrast, we believed a set of guiding principles could provide a flexible and responsive platform on which to base consultations and possible program development.

AIVL’s guiding principles are as a result of consultation with injecting

drug users who have been in prison within the last year, corrections health personnel and have also been informed by the current effective models in

place overseas.

AIVL’s key Guiding Principles for the

successful implementation of a PSE Program in an Australian prison are:

For any PSE program to become reality, it is vital that all stakeholders are included in every stage of the development and implementation. It is likely there will be differing views held by the various stakeholders with conflicting levels of support for such an initiative. PSE programs require long term commit-ment and support for them to succeed. A PSE program remains vulnerable to sabotage and this can result in failure. While challenging, it is crucial that all stakeholders must be involved to reach consensus. It can be better to not have a PSE program at all, than to have one that is not supported and run properly. Stakeholders may include but are not limited to:

• Injecting drug using prisoners;

• Non drug using prisoners;

• Government representatives from relevant departments;

• Prison staff and union representatives;

• Corrections Health and/or Department of Corrections

representatives;

• Representatives from the state or territory drug user organisations;

• Local Non Government Organisations (NGO’s);

• Representatives from prisoner advocate organisations including ex-prisoners.

Some programs currently operating overseas exclude some prisoners from accessing the program including individuals on methadone treatment, preg-nant women, those in reception, etc. AIVL does not support the exclusion of any individual from accessing PSE programs. Within the community, indivduals are not excluded from accessing sterile injecting equipment and this should

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1. Involvement of all stakeholders:

3. Initiation to the service should be by way of all new prisoners having a blood borne virus kit (e.g. Fitpack) placed in their cell:

2. The PSE Program should be made available to all prisoners:

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remain the case in the prison setting. Excluding individuals will result in the continuation of an underground “illegal” system which is counterproductive to the aims of any PSE program.

In the current models overseas there are various ways in which prisoners are initiated into PSE programs. AIVL however believes that the above approach is most beneficial because:

• It does not require an admission of injecting drug use by the prisoner;

• It is more confidential and is able to better protect prisoners anonymity;

• It provides greater protection to prisoners from being targeted by prison staff;

• It promotes greater accessibility and availability of equipment

and assists in the process of removing the ‘currency value’ of injecting equipment;

• The kit can include additional information such as safer injecting, overdose prevention and blood borne virus prevention as well as other drug using paraphernalia;

• Placing the kits in such a way also demonstrates that the prison is committed to protecting the health of all prisoners and removes many of the power dynamics in the prison setting.

Both of the above mechanisms for distribution have costs and benefits however, when they are combined, they have the potential for providing a more encompassing and holistic service that will increase health outcomes:

• Staff can play a role that machines alone cannot. This can include referral to other health services within the prison system, on the spot

information and advice, monitoring of the PSE program, provision of additional equipment that cannot be provided through the machine, drug

management strategies, referral to drug treatment and act as a reassurance for prisoners particularly should the vending machine become inoperable;

• Machines provide a low threshold mechanism of distribution for those prisoners who do not wish to have any contact with staff. This is crucial in ensuring that access is as easy and non-threatening as possible. Regardless of the commitment that each prison may have to the PSE program, there will be individuals who, for an array of reasons, are not comfortable or trusting of the program;

• The two mechanisms working together also provide ‘insurance’ to minimise the likelihood of never being able to access sterile equipment. For example if the machine is broken, then there is the option of accessing the staffed arm of the program and should a lockdown prevent access to the staffed arm, then the machine remains an option.

Vending machines provide a level of confidentiality and anonymity and are, if positioned correctly and maintained, an efficient yet expensive way to distribute sterile injecting equipment. There are however issues with this modality that also need to be considered. AIVL believes vending machines must meet the following principles:

• The positioning of the machine must not place users at risk of exposure; neither should it be placed in an insecure environment where it can easily be vandalised. This is a difficult principle to follow

and is a criteria that requires careful consideration, deliberation and possible compromise;

• The machine must remain stocked and fully functioning. Failure to do this will result in loss of faith by prisoners in the PSE program and it is likely that prisoners will revert back to an underground system which will be detrimental to all stakeholders. AIVL believes that where possible management of the vending machines is best placed with the NGO staff;

• Where possible, the machine should also contain other items such as soap or condoms. This adds to the confidentiality and anonymity for prisoners accessing the PSE program it also makes the machine of value to non drug using prisoners and is therefore less likely to be vandalised by either prisoners or prison staff;

• Staffed PSE programs are able to offer a fuller range of services and interventions such as health promotion and referral to other services for example drug treatment. Staffed PSE programs also remain as a back up should machines become a target of vandalism.

4. The provision of needles and syringes must be through both vending machines and external Non Government Organisation (NGO)staff:

5. Vending machines need to be well placed, regularly stocked and protected from vandalism. Where possible the machine should also provide other resources such as soap and condoms to protect confidentiality:

6. Staff operating the program should be from an external NGO who are less likely to gain personally from prison culture and systems and should be managed directly by the prison’s Governor:

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Difficulties with trust within the prison system between prisoner and prison staff and vice versa are well documented and recognised. While the prison service is working hard to rectify this dynamic, it must be recognised that a PSE program run directly by prison staff will be ineffective and unsuit-able. Models overseas of both NGO run PSE programs and NGO run drug treatment programs show better outcomes than those developed by prison

staff. These are good models that prove again that partnership initiatives can work well and that by working together great health outcomes can be achieved. (A good example of this is the work being done by various AIVL member organisations in relation to peer run overdose prevention workshops being held in some prisons.)

As has been mentioned, trust is vital and from the focus groups that AIVL undertook, former prisoners felt that the best management system for the staffed PSE program would be for the PSE program to be run directly by the Governor. Within prison culture, the Governor is most trusted and respected and this management structure would enhance the operations of the staffed PSE program. Clearly good policy and procedures need to be developed that promote and encourage supportive work environments, clear lines of management, transparent communication networks and evaluation and

monitoring.

As with services in the community there is a need for the PSE program to be able to be gender specific. While AIVL recognises that female staff have capabilities to abuse and oppress female prisoners, focus groups reported that gender specific services were preferred and more readily trusted. Female ex prisoners reported feelings of vulnerability when having to be reliant on male staff and this could potentially act as a deterrent to

using the PSE program.

It is vital that all staff involved in the PSE program are well trained and that training packages for staff are developed and delivered as part of condition of employment. Working within the prison setting can be challenging and difficult. Many individuals who have not been in the prison environment may find it to be alienating, emotionally draining, personally challenging and oppressing. Staff need to be able to cope with and manage an environment where the culture can be frightening. AIVL believes that staff with personal experiences of prison culture and drug use will be more effective

as they will be more able to empathise with the other prisoners and be more aware and alert to the prison culture. Such people have greater understanding of the pressure and challenges that injecting drug users face in prison and will have an investment in making the PSE program a success due to their personal experiences. It is vital that staff receive and participate in supervision with an experienced supervisor. Supervision

should remain confidential and readily available. AIVL recommends that, at a minimum, staff should receive monthly supervision.

Everyone employed in the PSE program remains at risk of being exploited both by prisoners and prison staff to the detriment of the PSE program. AIVL therefore recommends that staff work on a rotational basis so that such oppor-tunities are minimised. This will ensure greater protection for all stakeholders and a more successful initiative. This system also protects staff from burn out and high stress from working continually in such a demanding environment. In addition, AIVL recommends that regular team meetings take place to enable staff to debrief in a safe learning environment. As required, feedback to the Governor on any agreed issues should be undertaken.

PSE programs need to be delivered to quality standards and need to be regularly evaluated. As within the community, PSE programs should be

7. In female prisons, the PSE program staff should be women:

8. Staff must be well trained and supervised and where possible should have drug using experience and have experience first hand of prison culture

9. Staff should rotate so that they cannot become entrenched in prison culture and attend regular team meetings to be able to debrief:

10. The service needs to be non judgmental, accessible yet confidential and well monitored and evaluated:

11. A full range of injecting equipment needs to be made avail-able within the PSE program as is available within the community. Other services should also be available such as referral to health services, drug treatment and peer education/support initiatives:

12. Equipment should be kept in a designated container and area within each cell:

�

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delivered in a non judgmental way with good accessibility. While there is an expec-tation that PSE programs will indeed be run well, it is vital that they are run in a way that is transparent and accountable. It is imperative that prisoners who use the PSE are consulted upon in relation to the functioning and development of the program. Prisons operate in closed environments and it would not be hard for poor PSE programs to be in operation. External evaluation of the programs are vital for there to be a confidence in their provision not only for those using them, working within them, managing them and coordinating them, but also for the wider community.

Equipment availability from PSE programs should be equitable to that within community based Needle and Syringe Programs. As with the other functions of NSPs in the community, PSE programs must be able to refer prisoners to other health, welfare and social services available within the prison. It is important that prisons are encouraged to develop services internally with external partners to provide holistic drug services.

It is common practice overseas for prisoners to be expected to store injecting equipment in a designated container and area. This is a safety mechanism for prison staff and for other prisoners as the containers are puncture proof. In Bilboa prison in Spain, the staff provide prisoners with the same packs that they would get in the community. Within Australia it is likely that such packs could be for example ‘Fitpacks’. By agreeing an authorised area of storage, with appropriate protecting policy for the prisoner, safety is increased. Prisoners must be confident that having injecting equipment visible in the designated area of there cell will not result in unfair actions or sanctions for this model to be successful. The Swiss PSE program has noted that they may have decreased any chances of needle stick injury by using this model with many staff stating that with this model in place, needle and syringes have become easier to control. Finally this container will also ensure safe disposal and transportation of used injecting equipment within the prison.

Prison Staff require intensive training to increase their knowledge of the many aspects of injecting drug use and to increase their capabilities in providing services to their prisoners that is based on a model of health and human rights.

Such training must include input from injecting drug users who have experienced the prison system and the extreme difficulties that are experienced in protecting one’s health. In addition, the training should include input from NSP providers, alcohol and drug treatment programs and drug user organisations. The training should cover issues such as harm reduction; drug treatment options; health and human rights; peer education/support and space for the staff to explore their own discrimination and morals in relation to injecting/illicit drug users.

As within any organisation, prison staff must be supported to be able to carry out their work and to do so competently. It is important that regular training sessions be made available to staff so that they remain up to date on drug trends, health issues and treatment options. In addition, the values and atti-tudes of staff should be monitored via staff appraisals. Feedback should be sought from PSE staff on individual prison staff in relation to the PSE program. It is important that prison staff are enabled to carry out their work and that personal views are kept in check so that the PSE has a greater chance of success.

AIVL’s Plan of ActionAIVL has shown that there is a great deal of work that needs to be carried out, to make PSE programs a reality within Australian prisons. Over the coming year AIVL intends to:

• Seek dialogue and partnerships with all relevant stakeholders;

• Work with legal advisers in relation to clarifying and addressing legislative and regulatory barriers to implementation;

• Establish a national working group with representatives of all stakeholders to establish an achievable work plan to move this issue forward;

• Where possible influence research agendas to include PSE program issues;

• Investigate suitable environments for a pilot PSE program.

Some Final ThoughtsThere is injecting equipment in Australian prisons today. It is an underground system and it is utterly inadequate and dangerous. There is an abundance of evidence to show that legitimate PSE programs can provide enormous benefits to the entire community. Prisons have a duty of care to all prisoners. Currently there is not one prison in Australia that can say that they are fully meeting their duty of care responsibilities to prisoners.

In the debate about NSPs in prisons there is a lot of opposition and some genuine concerns. There was also a lot of opposition and fear prior to the provision of condoms in prisons. Then, as now, some corrections staff were very concerned about the condoms being used as weapons. In reality this has not occurred and the provision of condoms in prisons has been highly successful. Ultimately, the only way we were able to confirm or deny the fears about condom provision was to pilot them in prison and evaluate their impact.

AIVL believes it is time to take the same approach to the provision of PSE programs. The only way that we can answer some of the legitimate questions

13. All prison staff should undertake as part of their induction training program sessions that address all aspects of injecting/illicit drug use and models of health promotion and human rights:

14. Training should be offered on a regular basis and attitudes to prisoners particularly injecting drug users be monitored through staff appraisals:

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I lived in the US for five years, almost to the day. During that time I met an enormous amount of generous, warm, intelligent people. People that did not like the fact that the US Government oppresses other nations in their name and did not like their government holding a gun at the head of the rest of the world to follow their antiquated abstinence based and punitive drug policy. Not all of these people were drug users and a lot of them worried about my drug use and behaviour over a certain period of time, but that’s another story.

Dateline - Seattle, Washington 1995, 94?, 93? Anyway, sometime around then. I lived in the city that after the ‘grunge explosion’ of a couple of years previous, became the much reported on ‘Heroin

Capital of the World’. The ‘Lewinsky Affair’ was a few years away and the Y2K bug was only a distant murmur. I was living downtown almost oblivious to it all.

On the corner of 2nd Ave and Pike St, just up the road from the famous Pike Place Fish Markets, was a small card table that was set up at various times during the week. The table was usually surrounded by a contrasting and diverse crew, with the ever-present policeman on horseback monitoring goings on from a carefully negotiated distance. This was the King County Department of Health sponsored Needle Exchange Program. I later came to learn that the card table appeared in other discreet places around the inner-city and surrounding areas. Relatively young people who were neither welcoming or judgemental staffed the table. They were just there attending to the needs of the disparate group of drug users that populated the city.

The other needle exchange in Seattle was in the University District and was not sanctioned or funded by the state. A hippie looking guy who I later found out was called “Bob” staffed it. He was in the U-District almost every day and only sometimes did he decide to take the day off, leaving a friend to distribute the clean sharps. I often wondered what his story was and after much small talk and many exchanges I discovered he was neither an ex-user, a hippie do-gooder or a prospective saint. He had lost his non-gender specific partner to AIDS and spent the compensation money or payout, or whatever, restocking the self-funded, self-staffing NSEP. I have since learned that Bob, once the state funded NSEP was established was told to move-on and has to now work ‘guerrilla’ style, moving from place to place without his old regularity and dependability. He is one of the Drug War’s partisans.

There were always the obligatory pamphlets and health information that were distributed with the cotton filters, disposal container and clean fits. The subject of these pamphlets ranged from N.A meeting timetables to warnings about the infamous ‘Flesh Eating Virus’ that had plagued IV drug users in San Francisco and was “certain to move up the coast to Seattle!” to eventually take which ever limb we inject our drugs into. “It’s in the dope you know!” was what our friends ‘in the know’ would tell us. I never actually met anyone who even knew anyone who had suffered from this. Oh the lengths they will go to!

One day my partner and I picked up a pamphlet that offered twenty dollars to be interviewed, with more money offered at subsequent follow up interviews. It was free money! An eighth of a gram could be purchased for not much more than that and between us we could buy a quarter! I rang and made an appointment with what was called “The Raven Study”. This Raven Study involved having blood taken, and then being led through a maze of bookcases and into a miniature room. The questions mostly were about my drug use and if I shared and that kind of thing. Like I said, easy money!

here were no needle exchanges in the Roman Empire and it is often said there are no needle exchanges in the USA. Drug use in the Roman Empire was commonplace and while the Romans were at war with a lot of people, they were not at

war with the citizens in their community who chose to use drugs. In fact they used the Egyptian’s knowledge of narcotics quite freely for medicine and recreation (ancient home-bake?) It is true that harm reduction is not widely practised in the arena of drug and alcohol services in the US, however, as in any war, there are some pockets of resistance and even some state governments that will allow the practice of keeping drug users alive. In this environment, like any conflict, there are many accounts of bravery, service to the cause

NSEP

IN TH

E ROM

AN EM

PIRE

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Time went by, as time inevitably does, and I was reminded to attend another interview at the strange little office. I strode down to a part of town that was not Downtown but it wasn’t really a suburb either. There were rail-yards, the freeway to West Seattle was overhead and there were a lot of warehouses, kind of industrial I s’pose. There were cheap old diners and bars in which the inhab-itants only know what time of day it is when they are asked to leave at the end of the night. I like those kinds of bars.

I arrived at the office and was greeted by a worker who a few years later I would be introduced to as Chris, at a conference I attended. Chris spoke at me very matter of factly. “I have some good news, and I have some bad news” I thought he was starting a joke with which the punch line would end with an amusing double entendre. “The good news is...” he continued, “You don’t have HIV. The bad news is, you have hep C.” So much for pre-test counsel-ling! But his abrupt bedside manner had little negative affect on me, as I was only vaguely aware of what hep C was anyway. He gave me two pamphlets; one was not dissimilar to the one that brought me to him in the first place. This pamphlet contained some information about hep C and the second had the dates of my next appointments scribed upon it. “Read this” he said, and directed me to the front desk where I would receive my twenty dollars.

I remembered hearing on the radio when I lived in Sydney that they had discovered hep C. I thought it must be what you get if you don’t treat hep B and thought nothing more of it. Now, that I was armed with this new informa-tion about myself and a still warm photocopied flyer, I made my way swiftly to the nearest phone booth. On arriving at the phone I proceeded to punch in a series of phone numbers. I am always amazed at the ease in which I can recall the phone numbers of drug dealers, yet have difficulty remembering how old I am. I guess it is my brain auto-prioritising! The numbers were all for pagers (remember it is the nineties!) and after dialling I waited patiently for the first call back.

It was not a long wait. I picked up the phone and made an arrangement to meet a person who would give me a carefully weighed piece of sticky ‘black tar’ heroin. (I later discovered that keeping it in the fridge prevents it from becoming sticky, thus making it easier to divide). It is this crudely manufactured form of heroin I believe that contributed to the state of my veins today. ‘Black Tar’ is usually manufactured in Mexico and brought up the West Coast via various ingenious methods. When I’ve explained what this heroin is like to people in Australia, they often think, incorrectly, that it is like ‘smoking’ heroin. Similar to what is found and sometimes imported from Pakistan or India. I confess I don’t know how it’s made, but after applying much heat and filtering well, it looks like sump oil when it is in the fit. It feels the same as ‘our’ dope though.

This ‘drug seeking’, drug finding and drug doing, behaviour continued unabated for longer than I care to remember, only interrupted by the more mundane acts of survival like working, eating and avoiding the INS (Immigration and Naturalisation Services). During this time, I was a regular visitor to the little card table that kept me free of the need to sharpen, rinse

and re-use my fits.

Dateline — Seattle, Washington. The year: 2000. The hysteria surrounding the Y2K bug proved to be unwarranted. Even funny. The aftermath of the famous W.T.O Seattle riots was still resonating through the city. The T-shirt slogans had now changed from “I came to Seattle to score heroin and all I ended up with was a record contract!” to “I survived the WTO riots. Seattle, 1999”. I was sent to the “Seattle Heroin Overdose Conference”.

By this time I had been working at WASUA for about a year. When the opportunity to return to the place, and the people, that had played such an important role in the course of my life, I jumped at it. In fact, my manager was certain I would not return! I was returning as a professional. A person who was sent with a purpose, a mission, and I was determined to take in every sentence, every syllable, to report to my colleagues back home. I was returning to people who although they gave warmth and friendship, were still hesitant to engage with me. This hesitancy I believe stems from a fear of seeing before their very eyes, as in the past, my gradual disintegration. I was returning to NOT borrow money from these people!

The hotel where the conference was held was in downtown Seattle, only a few blocks from the apartment building where I used to live. As with most confer-ences, the breaks provide time to explore the surrounding area. As I was all too familiar with this area I decided to check in on some of my old haunts. The first place I headed for was the little card table. When I arrived at the spot where it used to be, it wasn’t there. This was not unusual and I returned to the spot the next day and the day after that. I found no card table on any of these days.

During one of the shorter breaks at the conference, I recognised a face that I could not put a place to. It gnawed at me for a couple of hours and then it hit me! The strange little office, the money, the Raven Study! I walked toward him and upon arriving at the group of people, a man I had met earlier that day introduced us. “This is Chris, he works at S.O.S (Street Outreach Services).”

The conversation I had with Chris revealed that “The Raven Study” I had participated in years earlier, was a needs assessment to evaluate the need for a needle exchange program in Seattle. We talked for some time and he invited me to visit his service and afterwards he would take me next door to the newly established King County Department of Health, Needle Exchange Program and Health Clinic. It blew me away! The brand new building was not unlike NSPs and NSEPs in Australia. It was not peer run, or even peer staffed, apart from some volunteers, but nevertheless, it existed! And I helped make it happen! I felt proud, I still do. Even though I was in a stage of my life where I was not using, I wanted to, just to use this amazing new needle exchange.

I am unsure where this pride came from. My primary motive for participating in the study was financial. If I had bothered to read one of the pamphlets my new friend Chris had given me all those years ago I would have realised the reasoning behind it. I guess, on reflection it was my first positive step toward drug user activism. A step that has led me to change almost everything I knew about drug use. A step toward making a difference (regardless of how I feel

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23rd February 2003India - Reuters Delhi cops opt for addicts over test kits on busts

NEW DELHI (Reuters) - Indian police have found something more reliable than sniffer dogs or imported testing kits when they need to quickly verify their latest drug haul is the real thing — junkies. Drugs sold on the streets of New Delhi, such as smack (brown sugar), hash and heroin are often so heavily mixed with anything from boot polish to household dust that police have no idea what they have, Sunday’s Hindustan Times newspaper reported. So they call on addicts [sic], going to particular slums for different drugs and paying their “tasters” a fee. “While drugs like opium and hash are easily detected by their smell, we generally get stuck with brown sugar and heroin seizures,” the Times quoted one officer saying. “In fact, sometimes even the imported testing kits give arbitrary results if the heroin is not of fine quality. That is when we call in the tasters. And they are never wrong.”

19th March 2003Thailand- Addicts shackled 24 hours a day to prevent “cold turkey madness”

Sunthorn Pongpao — A drug addict undergoing treatment at the Temjai rehabilitation centre in Wat Worachet Temple, Ayutthaya Province, sleeps while chained up. “Chaining drug addicts is an effective way to have them quit drugs” says one monk who runs a drug rehabilitation centre in Ayutthaya. Phra Thawee Ayuwatthago said at his Temjai drug rehabilitation centre in Wat Worachet temple yesterday that “drug addicts were chained around the clock for 10-30 days to prevent them from going berserk or damaging things while suffering withdrawal symptoms. Once this happened, patients underwent religious training and herbal treatment for three to four months, after which most quit drugs for life” he said. Public complaints over his methods prompted a delegation of public health officials to visit the temple yesterday. Ayutthaya public health chief Dr Thaweekiart Boonyapaisancharoen said he appreci-ated the intention of the centre to help drug addicts but chaining people was tantamount to torture and should stop. Ten drug addicts were found chained by their hands and ankles yesterday. The monks were also told to improve the hygiene at the centre. Phra Thawee said the patients would be unchained if proper buildings were constructed to contain the “mad addicts”.

15th April 2003US Congress Passes “RAVE Act”

In the US the “RAVE Act” Snuck Into “Amber Alert” Legislation without public notice, a hearing, or debate in Congress, the “Illicit Drug Anti-Proliferation Act” S.226 (a.k.a. the “RAVE Act”) was passed by both houses of Congress

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after being snuck into to the “PROTECT Act” S.151 (“Amber Alert” bill) in a conference committee. [You’ve got to fight for your right to PAAAAARTY!!!!]

21st April 2003 Peru — ReutersMissy RyanPeruvian Farmers March on Lima to Defend Coca Crop

Thousands of Peruvian coca leaf farmers marched into Lima on Monday demanding the government halt plans to eradicate their sacred cash crop, the raw ingredient of cocaine, and free their jailed leader. Men, women and children who have travelled for over a week on foot from jungle areas where coca leaf is a staple crop, marched with flags and banners from the outskirts of Peru’s sprawling capital towards the Presidential Palace. Most coca farmers insist they are not involved in the drugs trade and that their crops are grown for traditional Andean uses. Coca is used in tea, chewed to ward off hunger and fatigue and used in traditional Indian religious ceremonies. Farmers also want subsidies for lower-priced alternate crops like coffee, bananas and cocoa, as well as an increase in the amount of coca that can be grown legally. Washington, which has promised $300 million over six years to help Peru fight drugs, says more farmers are producing cocaine themselves.

22nd July 2003BrugerForeningenDenmark - In memory of dead drug users

On the evening of 21 July, a ceremony was held in central Copenhagen to unveil a new, permanent memorial dedicated to the memory of deceased drug users, victims all of them, in one way or another, of prohibition and its side effects - from overdoses, to the myriad unnecessary infections to which drug users are subjected.

A group of activists from the “Danish Drug Users Union” (“BrugerForeningen”) deposited piles of 63 stones in four public sites around Copenhagen. Each of the piles was accompanied by a placard in three languages explaining that each of the stones represented one of the 252 users who have died in Denmark in the past year, and that they will all be moved to the memorial site as part of this evening’s ceremony. The stones each bear a stamp reading

‘narcodeath’ and a hand written name, most of which are those of known indi-viduals- old friends, acquaintances, or faces from the scene.

30 April 2003The GuardianUK - Addict’s Family Wins $20,000

A heroin addict serving a prison sentence who became dehydrated and died after medical staff failed to monitor her withdrawal symptoms properly was subjected to inhuman and degrading treatment, the European Court of Human Rights in Strasbourg ruled yesterday. The court awarded the mother and two children of Judith McGlinchey, who died in 1999, aged 31, $22,900 compensation and $7,500 costs. The judges ruled six to one that the UK had violated Article 3 of the European Convention on Human Rights, which bans inhuman or degrading treatment. The judges also held unanimously that the lack of a route to compensation for her mother and children under UK law violated Article 13 of the European Convention, the right to effective remedy.

18th May 2003 Daily Telegraph (UK)David BammerUK - Yard Chief Calls for Drugs Trade to be Legalised

One of Scotland Yard’s most senior officers has called for hard drugs — including crack cocaine and heroin — to be decriminalised, saying that police cannot win the war against dealers. Chief Supt Anthony Wills, the borough commander of Hammersmith and Fulham in London, said that as the state could not control the criminal trade in drugs, it should take it over instead. “I would have no problems with decriminalising full stop,” said Mr Wills. “There have to be very stringent measures over the production and supply of drugs and we have got to remove the drug market from criminals. I do not want people to take drugs but if they are going to, I want them to take them safely, with a degree of purity and in a controlled way.”

30 May, 2003Andrei Rylkov, AIDS Foundation East-West (AFEW)Russian outreach workers registered first trade union

The first outreach workers’ trade union “Street Workers of Harm Reduction” was registered on the basis of organisation “Return to Life” (Moscow, Russia). Among the trade union primary goals are: establishment of stable outreach activity and work, increase of organisation members’ wages, creation of additional workplaces, improvement of service conditions for the organisation

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21st May 2003Four Year Trial of Medical Cannabis

Yesterday the Premier of NSW, Bob Carr, announced a four-year trial allowing cannabis use for medicinal purposes. Conditions which may entitle the person to be registered to use cannabis medicinally include: cancer; HIV/ AIDS; chronic pain and multiple sclerosis. Exclusions include:pregnancy; being less than 18 years old and criminal convictions other than minor possession/use charges.

In announcing the trial Bob Carr was quick to point out that this should not be seen as a green light for more widespread drug law reform. In media associated with the trial he has stressed that he is opposed to cannabis decriminalisation and supports this trial purely on the basis of compassion and medical evidence.

Drug user organisations have long held that a well-researched trial into the palliative care effects of cannabis, and particularly the nature of its interactions with other medications is quite overdue, and an important step in improving quality of life of drug users living with chronic illnesses.

7th June 2003AFP (French News Agency)Australian drug dealer gets tax back

A convicted heroin dealer in Australia has been allowed to claim a tax deduction for money he lost during a failed drugs deal. The Federal Court ruled on Friday that Francesco Dominico La Rosa, from Perth, was entitled to the money because the Australian Tax Office (ATO) had overestimated his income. The long-running battle between Mr La Rosa and the ATO began when he was serving a 12-year jail sentence for dealing heroin and amphetamines.

The ATO estimated Mr La Rosa’s income for the year 1994-95 as being A$450,000. But he insisted that his income was far less than that, because the ATO’s figure wrongly included A$220,000 which had been stolen from him during a failed drugs raid in 1995. He said he was entitled to a deduction because the loss was incurred as part of his business dealings. He took his claim to the Administrative Appeals Tribunal, which agreed in his favour. The ATO appealed, arguing that it was against public policy to allow a tax deduction for stolen money, but it was unable to overturn the verdict. Mr La Rosa welcomed Friday’s decision, saying that if the authorities wanted to tax his profits, they should also take account of his losses. “As drug dealers

or business people, we should have the same rights as any taxpayer,” he said, according to the French news agency AFP.

1st September 2003 Injecting room set to get another four years

The Kings Cross injecting room will continue to operate for another four years under legislation to be put to the NSW parliament this session. Special Minister of State John Della Bosca said “It has led to the saving of lives, it’s been an important advance in information, the evaluation has been successful and we’re extending the trial for another four years,” he told reporters.

The independent evaluation found more than 500 drug overdoses had been treated without a single fatality, and there was no increase in drug-related crime or drug dealing in the area. “The evaluators indicated that a small number of lives had been saved directly by the centre,” he said. “The government and I think the community is largely satisfied that that’s the case.” The centre costs $2.5 million a year to run and is funded by confiscated proceeds of crime. Mr Della Bosca defended the continued use of the term “trial”, saying more information was needed before continuing the “ground-breaking initiative” permanently. “We want more information,” he said.

The minister all but ruled out establishing similar centres in other suburbs, saying there appeared to be little community support for such a scheme in other areas. However he conceded that drug use was a continuing problem in the area. “If we’ve learnt one thing as a community, we’ve learned to be realistic about our problems, particularly our problems in relation to drugs,” he said. “And the fact of the matter is that the drug problem has been with us for a number of generations and it will presumably continue to be with not only Australia and NSW but the entire western world for some time to come. “What we need are better and more comprehensive strategies for dealing with it.”

Thursday 26th June 2003Australian Broadcasting Corporation News Online NT maintains highest imprisonment rate

The Northern Territory continues to have the highest imprisonment rate in Australia. Latest figures from the Australian Bureau of Statistics show for every 100,000 adults living in the Top End, 522 are likely to be in jail. This is more than three times the national average. In the past year, the number of Indigenous people in Northern Territory jails has risen by 31 per cent. Western Australia remains the state with the highest rate of Indigenous imprisonment, 21 times greater than for the non-Indigenous population.

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As part of ensuring that drug users have a say in the develop-ment of the Melbourne International Conference on the

Reduction of Drug Related Harm, Annie Madden AIVL’s Executive Officer, has been invited onto the Executive Program Committee (EPC) or the main organising committee for the conference.

To support her in this role, an International Drug Users Working Group (IDUWG) has been established made up of drug user activ-ists from across the world. The IDUWG includes people from United Kingdom, France, Germany, Russia, Slovenia, Canada, United States, India, Thailand, New Zealand and Australia (AIVL & VIVAIDS)

Some of the issues and work being done by the IDUWG includes:

• Organising a two day Drug Users Meeting in Melbourne before the International Harm Reduction Conference;

• Lobbying to set up a scholarship program to financially support drug users getting to the

conference;

• Working to make sure drug users coming to the conference from overseas don’t have visa prob-lems, difficulty with customs or with bringing medications into Australia;

• Working to set up flexible options for dosing for people who need to have methadone, buprenorphine and other treatments prescribed while in Australia;

• Developing a social program focussed on the local drug using culture;

• Having input into the draft conference program and proposed speakers;

• Identifying a speaker to deliver the drug user plenary presentation;

• Securing a place for AIVL to speak at the Opening Ceremony of the confer-ence;

• Participating in the meetings of the Executive Program Committee (this role is done by Annie rather than the working group);

• Having input into the various satellite events being organised alongside the conference;.

As you can imagine, it is not easy to work with such a large group of people from all over the world when the main form of communication is email. Nevertheless, the representatives on the IDUWG are putting in the effort in an attempt to ensure drug users and their issues are well represented at the Melbourne conference. It is a fantastic opportunity to have the International Conference on the Reduction of Drug Related Harm being held in Australia and AIVL is determined to make it clear to everyone attending the conference that Australia has a strong drug user’s movement and a long history of drug user advocacy.

We also want to encourage as many Australian drug users as possible to attend the pre-conference Drug Users Meeting, the main conference and to get involved in the social program, particularly Victorian drug users. We are aware international conferences are notoriously expensive and this one is no

As well as the normal wide range of topics, speakers and styles ofpresentation or discussion, the 15th ICRDRH will also concentrateon a number of major themes including:

• Policing and harmminimisation

• The economics of drugs• Local government, drug policy

and harm reduction• International treaties• Indigenous populations, drugs

and harm reduction

• Pharmacotherapies• Needle and syringe exchange

and harm reduction• Public health law and harm

reduction• Alcohol and harm reduction• The media and harm

reduction.

The 15th ICRDRH will combine cutting edge science withactivism, bring consumers and affected communitiestogether with researchers, practitioners and policy makers,and encourage and facilitate dialogue and understanding between all who have a commitment to humane and rational approaches to humanity’s relationship with drugs.

For further information please visit: www.ihra.net or email: ihrc2004conference@adf.org.au

INTERNATIONAL HARM REDUCTION ASSOCIATION

ADF - HR15Ad 180x110 8/9/03 3:24 PM Page 1

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Back in the 1980’s when most of my friends and I caught hep C, it was due to ignorance, lack of clean injecting equipment or just not caring. Since then, I have seen the rate of new infections rise from 11,000 per year in 1997 to 16,000 per year in 2001. Due to the amount of information available as well as clean injecting equipment being available through the many needle and syringe exchange programs, it poses a difficult question - Why? The only reason I can think of is that many people just don’t care. But believe me, once you have hep C, you have it for life.

It might take ten or fifteen years to hit you hard, but it will happen, and then there are the side effects you might not notice thinking it is just something else minor; lethargy, depression, a lowered immune system so that you get sicker easier, longer and more often. You might be one of the lucky few who’s body rids itself of the virus on its own - a bit like buying a lottery ticket.

There is no cure for hep C and as the clock keeps on ticking, it will hit you and may hit you hard. Just because you don’t see many people suffering badly from hep C, doesn’t mean you should dismiss it. The government doesn’t spend large amounts of money on something that is not serious.

With 200,000 people in Australia infected by hep C, if the current injecting practices don’t change, by 2020 there will be between 320,000 and 836,000 people infected with the HCV virus, and one of them could be you! If we don’t do something about drug users attitudes towards hep C (people with a history of injecting drug use are about 90 percent of all infections) it will just get worse. It may not hit you straight away, but it will hit you.

Research has shown that the hep C virus lives outside the body for longer than HIV and is a lot more infectious than HIV. But it seems everybody is a much more worried about HIV than hep C as the effects are a lot more noticeable and HIV has a higher mortality rate. But this picture is far too simplistic. The real issues in relation to hep C are far more complex than a straight comparison between HIV and hep C.

So why are people a lot more lax towards the possibility of catching hep C? Who knows? Do yourself and the future a favour, learn about hep C and do every-thing you can to avoid catching it. If you don’t, you and your family will be the ones who will suffer in the end.

How is Hep C Transmitted?Hepatitis C can only be transmitted by blood to blood contact. So in order to

HEPATITIS C . WHO CARES ?epatitis C rates amongst injecting drug users are continuing to rise and it seems, that at least part of the problem is whether people are taking the issue seriously enough. This personal article takes on some

of these difficult issues and makes an appeal to younger users to be more aware of hep C and its potential impact on their lives and futures...

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contract hep C, it is necessary for an infected person’s blood to be intro-duced into the bloodstream of an uninfected person. It is not necessary to be able to see the blood as the smallest amount is all it takes.

Be aware of anything that could possibly contain traces of blood. To be sure, always behave as if the blood is there and never share any injecting equip-ment or personal hygiene items that may contain traces of blood. Even if it is with a long term partner and you both have hep C, you could both have different genotypes and make your hep C worse by getting infected with more than one genotype. Even having the same genotype you could still be reinfected which could raise your virus levels and make things worse.

Just play it safe. As is the nature of viruses, they evolve and change constantly. It is for this reason that viruses are so hard to cure. So, any risk no matter how small you perceive it to be, is an unnecessary risk and not a

chance you want to take if you care about your health at all.

What About Testing?If you think you are at risk you should consider being blood tested. The test will check for antibodies to hepatitis C. Antibodies do not prevent infection but show whether you have been exposed to the hep C virus at some time and whether your body has produced hep C antibodies in response to this expo-sure.

There is also a stage known as the window period. The window period is usually a period between two weeks and three months (but can be up to six months) from the time of possible exposure. During this time a blood test may or may not show the antibodies, even though the virus may be present. There is a test however called the nucleic acid test that can detect the hep C virus after twenty three days.

If you present with a positive test it is necessary for the health department in your state or territory to be notified for their records but with no iden-tifying details. They use this information to count how many people have hep C in the state or territory and so they know the rate at which people are becoming infected. You are entitled to medical confidentiality at all times.

After a positive test it is necessary to have another blood test called a liver function test to determine the condition of your liver. It can take up to two weeks to get the results and this can be a very worrying wait for some people. Liver function tests can give you the level of information you need to decide about further tests and/or treatment.

Before you have a hep C test, it is important that you think about how you might react to and live with a positive test result. A good doctor will talk

with you about these issues before you make your decision to have a hep C test — this is called pre-test counselling. Getting a hep C diagnosis can be very serious and it affects each person differently. You should never feel forced to have a test for hep C.

Life After Testing PositiveYes, there is life after testing positive for hep C! To make things easier however, here are just a few helpful tips to follow. It is not advisable to drink alcohol especially binge-drinking; you should avoid medications that adversely effect the liver; and you should eat good healthy food.

Looking after your liver is really important if you want a good chance at a longer healthy life. It’s never too early to start. The liver is the only organ in the body that can repair itself but it really needs your help. The virus probably will never go away but you can do the right thing and try to minimise the added damage that you can do particularly by not drinking alcohol.

You also should talk with your doctor about having regular liver function tests so that you can keep an eye on what is happening. For example, if your liver function tests start to change it could be a sign that the virus is affecting your liver and you might want to think about treatment options.

What About Treatment?The main treatment available at the moment is called ‘combination therapy’ which is called this because it is a combination of pegylated interferon and a drug called ribavirin. Together these two drugs seem to produce much better results than just interferon on its own or ‘mono therapy’. There has been some treatment success (some people testing negative to the prescence of the virus) with combination therapy but it is expensive treatment and can be very hard to get (because you have to meet strict criteria and treatment is only available through liver clinics) and you have to go through a liver biopsy — which is not fun.

There are lots of issues that people need to think about before going on to treatment including the demanding treatment regime and potential negative side-effects from the treatment drugs. Interferon is associated with increased depression in some people and this can be an issue for some people on treatment for hep C. Studies of people with chronic hep C document rates of depressive disorders ranging from 22.4 to 28 percent which is about twice that found in the general population.

Reactions to hep C treatment vary from person to person though and it is a case of having to weigh up and consider all of the possible implications and side-effects for yourself so that you can make an informed decision.

On page 24 of this issue of Junkmail you will find an article about the issues current injectors may need to consider in relation to combination therapy by Dr. Greg Dore. If you want more information about the prevention and treat-ment of hep C contact your local drug user organisation for information and

...always behave as

if the blood is there and never share

any injecting equipment or personal

hygiene items that

may contain traces of

blood...

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Although relatively uncommon in comparison to most health problems injecting drug users encounter, it is extremely important for us to be aware of infective endocarditis (IE) for several reasons:

First of all, it has a high mortality rate, and almost always kills the patient if left untreated.

Secondly, it is often preventable. Knowledge of the symptoms of IE, early diagnosis and correct management are what makes all the difference to your recovery.

And thirdly, a hygienic injecting regime is crucial when avoiding the types of bacteria that cause endocarditis. In most cases, these organisms are strepto-cocci (“strep”), staphylococci (“staph”) or members of other species of bacteria that normally live on body surfaces, entering the bloodstream through a break in the skin, as happens, through injecting.

Explaining what endocarditis is requires a little translation of the name; “endo” - means inside, “card” - refers to the heart (like ‘cardiac’) and the “itis” bit signifies a process of inflammation. Combining all three gives you an inflammation of the inside of the heart, usually caused by an infection, but occasionally by a fungus.

In a nutshell, what happens is that the bacteria or fungus involved can collect in one of the four valves inside the heart which normally keep the blood flowing in the right direction. The bacteria grow to form ‘vegetations’ which then damage the valve and interfere with the normal flow of blood.

To give a little more detail, blood that flows across a heart valve abnormally will create an increased pressure gradient or slant. (See fig.1 on facing page) This causes the flow to become more turbulent allowing fibrin (an insoluble protein found in blood) and platelets (blood particles) to deposit on the surface of the valve. This will begin as a sterile vegetation but if an opportunity occurs for a bacterium to enter your bloodstream, (through unhygienic injecting practises for example), a single organism can be deposited in the fibrin and platelet mass, providing a perfect site for infection.

As the bacteria multiply they cause inflammation that promotes even more

his article, which is an edited version of a longer article published by our good friends at Black Poppy Magazine in the United Kingdom, takes a long hard look at INFECTIVE ENDOCARDITIS a potentially life-threatening infection of the heart valve. Mainly caused by bacteria entering the skin through injecting, it can be extremely unpleasant and has a nasty habit of ironing you out completely if left untreated. Know the signs and symptoms...

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fibrin and platelet deposition. The resulting infected thrombus is termed “a vegetation”. The infected vegeta-tion will send intermittent showers of bacteria into the circulation which results in fever in many people and occasionally a piece of the vegetation may break off and enter the circula-tion causing systemic emboli (clots). The growth eventually destroys the heart valve. (See fig.2&3 over page) The bacteria are able to maintain their presence in the bloodstream because the heart valves are an especially difficult place for the body’s immune system to reach in order to fight off the infection.

The more chronic variety can build up over weeks, sometimes months & symp-toms can be vaguer. A low-grade fever (less than 39.4 degrees C); chills; night sweats; pain in muscles and joints; a persistent tired feeling; headache; shortness of breath; poor appetite; weight loss; small, tender nodules on the fingers or toes; and tiny haemor-rhages (broken blood vessels) on the whites of the eyes, the palate, inside the cheeks, on the chest, on the fingers and toes and odd chest pains.

Acute endocarditis can appear extremely fast, most often occurring when an aggressive species of skin bacteria, especially a staphylococcus (which normally live quite happily on the skins surface), enters the bloodstream and attacks a normal, undamaged heart valve. Once staph bacteria begin to multiply inside the heart, they may send small clumps of bacteria called septic emboli (clots or bits of vegetation) into the blood-stream to spread the infection to other organs, especially to the kidneys, lungs and brain.

Unfortunately, injecting drug users are at high risk for acute endocarditis, since injecting allows aggressive staph bacteria many opportunities to enter the blood through broken skin and unhygienic drug paraphernalia. If untreated, this form of endocarditis can be fatal in less than two months.

Endocarditis can also occur more slowly. This chronic form of IE is most often caused by one of the viridans group of streptococci (Streptococcus sanguis, mutans, mitis, or milleri) that normally live in the mouth and throat. A slow and insidious progression that occurs over weeks/months and if left untreated, it can progress for weeks, months, even as long as a year before it too, is fatal.

Risks for Injecting Drug UsersThe chances of getting endocarditis are mainly determined by how easily the bacteria can gain entry to the body and how easy it is for them to grow on the heart valves. Obviously, consistent care must be taken to avoid bacterium entering into your injecting routine.

The primary bacterium which affects drug users is called Staphylococcus aureus (often shortened to S. aureus). This is the very same bug that can cause things like septi-caemia, cellulitis, and abscesses. This is why, if you have an infected sore on your skin, you must take extreme care to avoid spreading the bacteria to your injecting site, allowing potential entry into your bloodstream or deeper skin tissue. There’s also a long list of other bugs but they are relatively rare and tend only to cause prob-lems in people with a compromised immune system, such as with HIV/AIDS.

As an injecting drug user, your risks increase even further if you; drink heavily; have had endocarditis in the past, have HIV/AIDS, or any other disease that affects the immune system; a malformation of the heart or heart valve present from birth; an implanted device in the heart (pacemaker wire or artificial heart valve); cancer with chemotherapy; a history of chronic illness. If any of these affect you, you should be offered preventative antibiotics whenever you have things like dental surgery done which might introduce infection.

Any injecting user with a compromised immune system should insist upon taking antibiotics both before and after any dental or medical procedure to reduce the risk of contracting endocarditis or, at the very least, ensure you have a full discussion with your doctor or dentist about the risks.

PreventionPrevention, for injecting drug users, comes with hygienic injecting practises. To prevent endocarditis, your doctor and dentist may prescribe antibiotics before you undergo any medical or dental procedure in which bacteria have a chance of entering your blood. Antibiotics are usually administered to patients who have had endocarditis in the past and patients with other high risk

Figure

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conditions (see Risks for Injecting Drug Users). In general, antibiotics are given one to two hours before a high risk procedure and up to eight hours afterward.

Before a dental procedure, an antiseptic mouth rinse also can be used, especially, one containing chlorhexidine or povidone-iodine. Our hygiene article this issue covers more preventative practices to avoid exposing your-self to IE. Endocarditis is not transmitted directly from person to person.

Remember, since the bacteria that causes IE is found on the skin or in soft tissue infections like abscesses or cellulitis, if you have infections such as these, you need to pay particular care to ensure that your injection site and injecting paraphernalia, are as hygienic and/or sterile as possible. This will help to prevent the bacteria entering your bloodstream. Licking your spike (or your injection site before or after a fix) is another way of transferring streptococci bacteria that could be living inside your mouth or throat due to abscesses or throat infections.

TreatmentYour doctor may suspect endocarditis based on your medical history, risk factors and symptoms, gathering additional evidence from a physical examination (see symptoms) and drawing blood samples. Other tests include an Echocardiography (ECG), where sound waves are used to outline the structure of the heart, heart chambers and valves. The first line of defence is a combination of antibiotics given intravenously, in a course

which normally lasts for six weeks and it also requires a fairly long hospital admission of six weeks or more.

Drug users are usually affected on the right side of the heart which pumps blood to the lungs - in contrast to the other forms of endocarditis, which normally affect the valves on the left side. This can make little difference to the complications that can be encountered. The difference comes in terms of treatment. Left-sided valves can be relatively easily replaced surgically, but replacing a right-sided valve is a more difficult operation with lower success rates, and because of this, does not tend to be attempted. This means that the affected person, even if treated successfully with antibiotics, can still be left with a permanently damaged valve and will be more prone to heart problems, including further attacks of endocarditis, in later life.

Tips to Remember:1. Never EVER lick, touch or blow on your spike or works before a hit.

2. Never inject near any skin infection or wound, no matter how small.

3. If you have a heart condition, HIV/AIDS (or a compromised immune system) or have had Endocarditis in the past - tell your GP and dentist before surgery to receive preventative antibiotics.

4. Never cough, sneeze on/near your gear.

5. Never pick or squeeze pimples or sores in between hits (as you might do on the coke). If you can’t help yourself then ensure you seriously wash your hands and fingers well afterwards and always wash your hands well before and after a hit.

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left Darwin in early April 2003 with many emotions. Fear, guilt, excitement, stressed out about problems at home and

was brought back to reality watching the customs sniffer dog in action as I waited to board my flight. I was going to the 14th International Conference on the Reduction of Drug Related Harm, in Chiang Mai, Northern Thailand, organised by the International Harm Reduction Association (IHRA).

Most users would ask — “what the f**k is IHRA? What is harm reduction?” You see, most users of illicit drugs would never have heard of IHRA or the IHRA conferences. I

am one of the lucky people - a drug user who has been made aware of the harm reduction movement and more importantly, the international drug user’s movement. While I do not intend to address the issue of user involvement here, I think that it needs to be addressed by the international drug user’s movement.

The current Thai ‘war on drugs’ is what made this conference so different from other IHRA conferences. On February 1, 2003, the Prime Minister of Thailand, Thaksin Shinawatra declared the commencement of the ‘war on drugs’ in Thailand, and that the country would be “drug free” by the end of April. Thaksin has already set dates to declare victory, and one province has reported a 105 percent success rate. Like many other countries around the world, Thailand has been fighting a war on drugs for decades, but Thaksin made a number of changes.

A new law was passed, the Drug Addict Rehabilitation Act that requires persons arrested for using heroin, methamphetamines, amphetamines, cocaine, opium and/or cannabis to undergo rehabilitation or face prosecution. The Thai probations department is considering adding solvents to this list. Drug users are being encour-aged by police to ‘surrender’ for drug treatment. Not surprisingly, many have. The government claims over 50,000, despite the appalling lack of drug treatment

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facilities in Thailand. People are being forced into boot camps oper-ated by law enforcement agencies.

Thaksin committed his regional governors to enforce ‘drug suppression’ efforts and made them responsible for ensuring that police reach their quotas, in terms of drug users and dealers arrested, drugs impounded and tainted property seized. This has

resulted in a zero tolerance policing frenzy by the Thai police with the involvement of Royal Thai Army (RTA) units.

US narco-agents are present in Thailand (they were even at the IHRA conference), in a training and support capacity, assisting the Thai police and the RTA with ‘drug suppression’ efforts. There is no prize for guessing who is pushing the current ‘war on drugs’ in Thailand. With US support, the Thai government has taken an outrageous approach to dealing with its drug issues.

The Thai government has established a drugs blacklist that lists people who are suspected of ‘drug involvement’. Various Thai government departments continue to squabble over who can have access to this information. In some villages, volunteers are trained, each to watch over between ten and twenty houses and to report any ‘drug involvement’ to police. In essence, it seems that the Thai authorities are asking people to spy on one another.

All emphasis has been put on ‘finding the minor users, dealers and offenders’. In their words, ‘to flush out the small timers.’ Nightclubs across Thailand have been forced to close early, and are now being raided with regularity by Thai police. During these raids, all patrons are urine tested, and anyone testing positive to certain

chemicals will be forced to attend a six week boot camp, be imprisoned or worse. Foreigners, who have previously been ignored by police, are now being urine tested during these raids. A Chiang Mai magazine reported that since February, eight farangs (foreigners) have been arrested after testing positive.

Since the commencement of this ‘war on drugs’, over 3000 people, including a baby, have lost their lives. Most have simply been shot on the side of the

road somewhere and left for dead. Police are claiming that rival drug-gangs are responsible for the killings, or that police have only shot people in ‘self defense’. The police have no evidence to support this and drug user activists within Thailand have pointed out that the police are involved with what have been dubbed ‘extra-judicial’ killings.

Many human rights organisations including Amnesty International and the Asia Forum Human Rights Group have condemned the killings. The United Nations have also expressed some concern. Thaksin simply stated that “they (the UN) are not my father”. International media however have been slow to respond to the bloodshed. The BBC in the UK and the ABC and SBS in Australia have run stories on the Thai ‘war on drugs’ but this has only been sporadic. We are not getting a constant information flow in the mainstream media in Australia and this seems to be the case around the world. The Thai press seems to be pushing the government’s hard-line approach with many articles that are basically government propaganda.

In terms of harm reduction, there is much work to be done in

Thailand. Heroin remains the drug of choice in Thailand followed by metham-phetamine and opium. The Thai Drug Users Network (TDUN) has stated that the ‘war on drugs’ is affecting all drug users, not just users of methampheta-mines. In 1987, Thailand experienced its first outbreak of HIV infection among injecting drug users and it was estimated that 40 percent of injecting drug users in Thailand were HIV positive.

Kerri Tucker Green MLA arrives at the rally.

Protesting outside the Thai Embassy in Canberra.

Against this repression, struggle the Thai Drug User Network (TDUN). TDUN is a group of former and current drug users who have come together to advocate on behalf of Thai users. TDUN held their first protest action at the IHRA conference — wearing T-shirts saying “respect the rights of drug users — Thai government drug

policy = drop dead” in English on the back and in Thai on the front. The Thai users held up placards and spoke on a megaphone. As the conference began the TDUN and, in solidarity, a number of interna-tional drug user activists, moved to the rear of the main plenary hall.

The Thai Ministry for Public Health was a sponsor for the conference so the Thai Minister for Public Health, Mrs. Sudarat Keyuraphan was one of the speakers at the opening ceremony. As Sudarat spoke, the TDUN group moved forward with placards held high. The group remained silent, but this gesture was more than enough to draw attention from the health minister to the activists.

There was one moment of angst during this protest, when armed police entered the main plenary hall and spoke to members of TDUN. The police left before the health minister spoke so they were not present (in uniform) during this protest. This was an extremely brave action by the Thai user activists, especially with the ‘drugs blacklist’ and the current ‘war on drugs’. Many conference delegates expressed concern about the safety of the Thai user activ-ists who participated in the protest and the conference in general. Since the conference ended, we have only been able to stay up to date through email contact.

JUNKMAIL #6 23

In fact, many conference delegates were not aware of the plight of the Thai drug users. International drug user activists had debated whether or not to attend the conference and many chose to boycott it because of these major human rights abuses. A small number of drug user activists did attend the conference and were able to meet with their Thai counterparts. For those of us

that did attend, it strengthened our resolve to work towards the end of the global ‘war on drugs’.

Many drug users in Australia often have a ‘bitch’ or a ‘whinge’ about their situation and I have been known to do this myself. After visiting Thailand it is clear to me that the oppression we face as drug users in Australia is absolutely nothing when compared to the oppression currently being faced by Thai users. Those of us in the so-called ‘devel-oped’ countries need to rally behind our sisters and brothers in the ‘developing’ world.

The ‘war on drugs’ in Thailand has all the characteristics of classic US imperialist policy. A zero tolerance approach, training and support from US narco-agents, targeting of indigenous groups and ethnic minorities and the involvement of military forces, the RTA. The parallels between the ‘war on drugs’ in Columbia and that in Thailand are clear for all to see. Unfortunately, the US government will continue to meddle in the domestic policy of ‘developing’ nations. Users need to get out into the streets and demand an end to this inhumane, stale and moralistic

approach to currently illicit substances.

When protesting for our rights in Australia, we should have some focus on international solidarity. We are being persecuted in our country because of US policy, the Thai user community and many Columbians have also been persecuted due to this interference. This is the common thread that we as users in the ‘developed’ world have with our sisters and brothers in developing nations. When we demand ‘stop the war on drugs’, we need to be referring to all aspects of the war on drugs, in the many shapes and forms that it appears.

Relevant Websites:

AIVL www.aivl.org.au

Territory Users’ Forum www.tuf.org.au

Network Against Prohibition www.napnt.org

International Harm Reduction Association www.ihra.net

Asian Harm Reduction Association www.ahrn.net

Bangkok Post www.bangkokpost.com

Footnote: On Thursday 12th of June, 2003 the international drug user’s

by

Gary MeyerhoffRoslyn Dundas Democrat MLA speaks at the rally.

JUNKMAIL #6 2�

ntil relatively recently, current injecting drug users (IDU) were excluded from accessing the available treatment for hepatitis C due to restrictions in the government guidelines governing treatment access. Fortunately this has now changed, particularly given that IDU are the group most affected by hepatitis C. In this informative article, Dr Greg Dore from St Vincent’s Hospital in Sydney and the University of NSW looks at the changes that have allowed access for IDU to the current range of hepatitis C treatments and asks whether hep C treatment is the right option for people who are currently injecting...

Initial poor results from hepatitis C treatmentSeveral years ago, my advice to people with hepatitis C was that they should not consider interferon-based treatment. This advice was for all people with hepatitis C, irrespective of factors such as current drug use. There were several factors that influenced my thinking at that stage in relation to hepatitis C treatment. First, interferon alone (monotherapy) was the only therapy available and the success rate was only 10-15 percent. Thus, seven out of eight people who were treated for between six and twelve months did not have a sustained or long-term response to treatment (viral clearance). Second, side effects from interferon therapy were considerable. Most people developed flu-like symptoms and one in three developed depressive symptoms. Third, having come from a background in HIV treatment and care, I felt that treatments would improve (as they did with HIV in the mid-1990s), and that combination therapy would be the answer to improved outcomes for people with hepatitis C.

Marked improvement in treatment outcomes from combination therapyCurrently, I am a strong advocate for improved access to treatment for all people with hepatitis C. The main reason I have changed my attitude to hepatitis C treatment has been the results of trials of combination interferon and ribavirin therapy. The initial trials compared interferon monotherapy to interferon and ribavirin combination therapy, with sustained response rates (viral clearance) of around 15 percent and 40 percent, respectively. Further information has shown that the vast majority (>95 percent) of people who reach a sustained response (measured as a negative PCR test for the virus six months after completion of therapy) are still free of the virus six to seven years later and that liver damage

generally repairs itself. The repair of liver damage in people with viral clear-ance even occurs in those who have cirrhosis at the time of treatment. Thus, more clinicians and researchers are comfortable using the word ‘cure’ in relation to people who have had a sustained response to treatment.

A new form of interferon therapy on the horizonThe initial marked improvement in treatment response with combination interferon and ribavirin has been followed by further improvements with a new form of interferon, pegylated interferon (which is still combined with riba-virin). Combination pegylated interferon and ribavirin therapy has produced sustained response rates in the range of 50-60 percent. In addition to improved efficacy, pegylated interferon and ribavirin is more practical as the interferon injections are only required once a week — in contrast to the three times a week for the standard interferon. Ribavirin is given in tablet form twice a day. Combination pegylated interferon and ribavirin therapy should be available through the government funded S100 scheme later this year.

The improved treatment outcomes with combination therapy are certainly positive news. The down-side is that treatment toxicity remains a problem, with added side effects (such as anaemia) from ribavirin. Although one in two people being cured with current treatment is a vast improvement from one in eight several years ago, hepatitis C treatment remains a difficult proposition for many people.

How does improved treatment change the situation

Should People with Hepatitis C who are Currently Injecting Drugs Consider Interferon and Ribavirin Treatment?

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for current injectors?Until May 2001 people with hepatitis C who reported current injecting were excluded from access to government-funded hepatitis C treatment. Since approval of combination interferon and ribavirin therapy, this barrier to access has been removed for current injectors. However, many barriers remain in relation to provision of treatment and care for people with hepatitis C who are current injectors.

There are several factors that need to be considered in decisions around hepatitis C treatment for current injectors. These include:

• effectiveness of treatment;

• pattern of drug use and risk of reinfection;

• duration of infection and extent of liver damage;

• hepatitis C genotype;

• support services provided by treatment clinic;

• social and family support structures.

Effectiveness of hepatitis C treatment among current injectorsThe sustained response rates given above for combination therapy come from clinical trials that have excluded people with hepatitis C who report current injecting. However, recent studies have shown close to comparable results among groups traditionally excluded from these trials, such as people who currently inject, have a history of severe psychiatric illness, or are on methadone or other drug dependency treatment. These studies have been relatively small, therefore larger studies are required. Other studies are required to examine hepatitis C treatment knowledge, attitudes and barriers among people who currently inject drugs. These studies should not, however, delay improved access to hepatitis C treatment.

Pattern of drug use and risk of reinfectionSome behavioural factors do appear to have an influence on treatment outcomes among current injectors. People who inject daily or more frequently appear to have a lower chance of treatment success than those who inject less frequently. Hepatitis C treatment may not be a priority for people with frequent injecting, with other health and social factors appropriately taking higher priority. The risk of reinfection may also be higher in people with frequent injecting. Ongoing exposure to hepatitis C through sharing of injecting equipment and subsequent reinfection is certainly a possibility, and is one of the reasons given by clinicians for withholding treatment from current injectors. However, I believe the vast majority of people who are prepared to take on a difficult course of hepatitis C treatment are using safe injecting practices. As such, the risk of reinfection may be very low, but counselling for current injectors considering treatment should certainly cover reinfection.

Duration of infection and extent of liver damageLiver damage in hepatitis C is produced through ongoing inflammation

and scar tissue development (fibrosis). Among people with chronic hepatitis C (generally defined by a positive PCR test for the virus), 50-60 percent will develop some fibrosis but only 10-20 percent will develop cirrhosis. Furthermore, the development of progressive fibrosis is a slow process, with 20-30 years generally required before cirrhosis develops. Thus, a person who has been infected for say five years is highly likely to have no or minimal fibrosis, and as such there is no great urgency for treatment. On the other hand, a person who commenced injecting in the late 1970s or early 1980s and could have been infected with hepatitis C for greater than twenty years may have already developed severe fibrosis or cirrhosis. Prevention of further liver damage would therefore be a high priority in such a case.

Unfortunately, a liver biopsy is the only reliable method for assessing the extent of liver damage. In general, I advise people with chronic hepatitis C who may have been infected for longer than ten years (based on the duration of injecting, not time from diagnosis) and have abnormal liver function tests to consider a liver biopsy. In those people who have mild liver disease (no or minimal levels of fibrosis/scar tissue), I generally advise not to commence treatment. In contrast, those who have progressed to moderate or severe fibrosis, or cirrhosis, I advise commencement of treatment.

Hepatitis C genotypeThere are several genotype or strains of hepatitis C, with genotype 1, 2 and 3 the most common in Australia. There is an association between genotype and treatment response, with viral clearance with combination therapy seen in 30-40 percent of people with genotype 1 compared to 70-80 percent for genotype 2 or 3. All people with hepatitis C who are considering treatment should have a hepatitis C genotype (a blood test); although at present this is only available through a specialist clinic. People with genotype 2 or 3 also only require six months of treatment, whereas those with genotype 1 require twelve months.

Support services provided by treatment clinicAlong with a non-discriminatory attitude to people who inject drugs, hepatitis C treatment clinics should be able to provide support services for drug and alcohol counselling and treatment and psychiatric review. These services will not be required for all people, but certainly should be available. Specific hepatitis C nursing support is also crucial for monitoring of treatment side effects and overall management. In future, hepatitis C clinics should be established at the primary care level including clinics that specifically service the injecting community (at present treatment is only available through large hospital clinics), as many people with hepatitis C may feel more comfortable in this environment.

Social and family support structuresThe support of family and friends is important for many people undergoing hepatitis C treatment. Factors such as possible mood disturbance on treatment need to be considered and discussed. A supportive work environment can also help, as often work arrangements need to be altered due to clinic appointments and side effects of treatment.

Finally, the most important aspect of treatment consideration is that individuals

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Federal Government Retractables Initiative — What have they been up to?

Since the last issue of Junkmail there has been a flurry of activity at the Departmental or Government level. Some of the main developments have been...

Reduction in Funding — in the May 2003 Federal Budget the Government announced that they were reducing the original amount of funding allocated to the Retractable Needles & Syringes Initiative by $10million. This reduced the funding from $27.5million to a mere $17.5million over three years.

Reduction in Scope — with the reduction in funding came a reduction in the scope of the initiative. In the last issue, we reported that the Australian Government Department of Health & Ageing had undertaken a series of national consultation forums with the various stakeholder groups potentially affected by or directly involved in the initiative — the injecting drug use

sector, the healthcare sector, the diabetes sector and industry representatives. Following these consultations, the Government decided to reduce the scope of the initiative to only focus on injecting in the community — that means us! The reason given for no longer including healthcare workers and diabetics in the initiative, was that in the consultations, these groups apparently made it clear they did not want to participate in the initiative and that they did not perceive any benefits in relation to implementing retractable needles and syringes in their areas. AIVL finds this particular reasoning quite interesting given the injecting drug use sector was nothing short of vehemently opposed to the initiative and to effectively forcing injecting drug users to use retractable needles and syringes. So, despite the loud protest from almost everyone in the injecting drug use sector, the initiative has now been reduced to focus exclusively on implementing retractable needles and syringes with injecting drug users.

Implementation Reference Group (IRG) — not long after the Federal Budget announcements to reduce the funding and scope of the initiative, AIVL

n the last issue of Junkmail we provided an update on what AIVL and the Australian Government have been doing on the issue of retractable needles & syringes. Some readers may be aware this issue has been building more and more momentum over the past twelve months. As it now seems inevitable that the Australian Government will pilot a number of different brands of retractable needles & syringes some time in the next few months, it is time for AIVL, its

member organisations and individual injecting drug users to get really serious about this issue. To make sure drug user organisa-tions and drug users are up to date on the latest developments in relation to retractables, AIVL will be providing this regular update in each issue of Junkmail. The following article updates readers on where the Australian Government’s Initiative is up to and on what AIVL has been doing to represent users on this issue...

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received a letter inviting us to participate in an Implementation Reference Group being established to “provide independent advice on the implementation of the initiative to the Department”. AIVL accepted this invitation as we have made an organisational decision that we are better ‘sitting around the table’ in terms of representing the interests of injecting drug users than being locked out of the process and information. This is a tricky balance for AIVL and we have gone into the process with our eyes wide open — we may yet leave. The first meeting of the IRG was held on 22nd July. The main issues raised and outcomes from this first IRG meeting were:

a) Terms of Reference: a set of Terms of Reference were discussed and endorsed to guide the group in its work and to spell out the role

of the IRG.

b) Why Retractables: members, in partic-ular AIVL, questioned whether introducing retractable needles and syringes into Needle and Syringe Programs (NSPs) was the most effective strategy for addressing community safety concerns in relation to discarded used injecting equipment. The Department made it clear that the Government is committed to investigating the suitability and acceptability of the technology by injecting illicit drug users.

c) Ethical Issues: IRG members identi-fied a number of significant issues which need to be considered prior to conducting pilot studies. In particular, AIVL raised many ethical issues and concerns such as ensuring that drug users have a choice of equipment and are not forced to used retractables during the pilots; duty of care

concerns if someone was to contract HIV or hep C during the pilots; concerns about whether researching retractables is even ethical given the lack of obvious health benefits to the research subjects and ethical concerns about the level of involvement of injectors in all stages of the research pilots.

For their part, the Department said that ethical considerations would be well researched prior to undertaking pilot studies, and that the IRG would have a role in providing advice to the Government. It was therefore agreed that once a research consultant has been engaged by the Department of Health and Ageing, the researcher will meet with IRG members to present a preliminary methodology for pilot studies, including ethics related issues. The AIVL representative at the meeting stated that AIVL was very concerned that the research consultant involved drug users

adequately in the all aspects of developing the research design and in identi-fying and addressing ethical issues associated with the pilots.

d) Risk Management: a draft ‘risk management plan’ for pilot studies was submitted to the meeting for discussion. Members of the IRG identified a lot of additional risks to be included in the draft plan put together by the Department. The Department agreed to finalise the risk management plan, incorporating the comments made by IRG members.

e) Call for Applications for Product Information: the IRG members were also told the Government would be putting out a “Call for Applications for Product Information” (which will lead to the purchase of retractable needles and syringes for use in the pilot studies).The Government had previously put out a “Request for Information” process in September 2002, and during that process it was found that several overseas manufacturers of retract-able devices had Australian distributors. For this reason the “Call for Product Information” would only be advertised in Australia. The Department also stated that through this initiative, there is no intention on the part of the Government to endorse any particular product or brand name.

f) MCDS Criteria: IRG members were told that the MCDS criteria “for the development of retractable needles and syringes for use in Needle and Syringe Programs by people who inject drugs illicitly” would be used as an assessment criteria to assess the suitability of retractable devices for pilot studies. (These criteria were developed by the Ministerial Council on Drugs Strategy (MCDS) back in July 2001. Although AIVL was consulted on the criteria when they were developed, AIVL is not happy that “acceptability to drug users” is not one of the MCDS criteria. If readers would like a copy of the MCDS criteria please contact the AIVL office on ph: (02) 6279 1600 or anniem@aivl.org.au”

g) Size of the Market: one of the questions raised by the members of the IRG was the size of the market for retractable needles and syringes, particularly given that the health care and diabetes sector are no longer part of the initiative. The Department noted that proponents of retractable technolo-gies may look to international opportunities for the marketing of successful devices. This raises a number of concerns from AIVL’s perspective, particularly the potential for aggressive marketing of retractable needles and syringes in an effort to expand markets. It is an issue AIVL will be watching carefully over the coming months and years.

h) National Audit of Community Disposal Facilities: one aspect of the Retractables Initiative is to conduct a National Audit of Community Disposal Facilities. At the first IRG meeting the point was made that there are many very successful disposal programs already operating at the state and terri-tory level and that safe disposal is not the problem it is often made out to be. It was acknowledged that disposal was an issue for both the diabetes sector and the illicit injecting drug user sector and agreed there was a need for more research into inappropriate disposal of needles and syringes. AIVL raised the concern that inconsistent approaches to disposal at the state and territory level were causing confusion amongst drug users. It was agreed that AIVL’s recent National Disposal Study (April 2002) be distributed to IRG members. The Department of Health and Ageing also confirmed that community based

...AIVL raised many ethical

issues and concerns such

as ensuring that drug users

have a choice of equipment and

are not forced to used retract-

ables during the pilots...

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disposal facilities for people with diabetes who inject insulin will also be considered when conducting the National Audit of Community Disposal Facilities.

i) Keeping Drug Users Informed: AIVL raised a question at the IRG meeting in relation to how much information from IRG meet-ings could be passed on to stakeholders following each meeting. AIVL stressed that it had a responsibility to inform and consult

with its member organisations and injecting drug users on developments in relation to retractable needles and syringes. Other members of the IRG expressed similar concerns. Given that each member of the IRG was required to sign a “Deed of Confidentiality” before joining the committee the Department agreed to look into this matter and get back to members on what information could be disseminated amongst their member organisations or stakeholders.

j) National Consultation Report: everyone who attended the State/Territory national consulta-tions in 2002 were advised that findings from the consultation would result in a report to the Department to inform the future implementation of the initiative. They were further advised that the Report was for internal use only, not for public distribution.

k) IDU Boycott: the final issue discussed at the meeting was whether injecting drug users would boycott the pilots of retractable needles and

syringes. The Department expressed the concern that a boycott would only result in no useful data and no real indication of what drug users thought about the devices. It was thought that drug users may not be served well by such a result. In response, AIVL made it clear that it had no intention of trying to influence the choice of their members to participate/not participate in the initia-tive. AIVL simply stated that it was confident that IDUs would decide for themselves whether to use the technology or not.

Although we have provided a fairly lengthy report on the first meeting of the IRG, we think it is important to give drug user organisations and drug users as much information as possible about what is happening at the national level and specifically, what is going on at the IRG meetings. AIVL’s representation of the issues is only as good as the information and intelligence that we get from you on the ground. So, if we want informed opinions from you, we need to make sure you have access to the latest developments.

What else has AIVL been doing on

Retractable Needles & Syringes?As well as attending the IRG meetings, the AIVL Policy Program staff have been doing other work in relation to retractable needles and syringes. Some of the other work on this issue includes:

• Responding to requests from our member organisations and other non-government organisations for information in relation to retractables;

• We are currently producing a six monthly update news-sheet on retractable needles and syringes for the AIVL member organisations, other national non-government organisations and individual drug users. The first issue of this update will be distributed in November. Look out for it!

• Presenting at conferences, national forums and other events on the ‘injecting drug user perspective’ on retractable needles and syringes;

• Writing regular updates in Junkmail;

• Meeting with key federal politicians about our concerns in relation to retractable needles and syringes.

What can I do as an Individual Drug User?The clock is ticking on retractable needles and syringes. It is only a matter of time now before the pilot studies begin in a local NSP near you! Injecting drug users need to get informed on this issue. It’s no good complaining once they are here to stay. The time to make our opinions and voices heard on this issue is NOW! Some of things you and your friends can do to are:

Read the article on retractables in Junkmail Issue 3 April 2002 — this article outlines some of the concerns and health issues you need to consider in relation to retractable needles and syringes. (Your local drug user organisation is likely to have copies of Junkmail Issue 3). The contact details for your local group are on the back of this issue. Otherwise you can call the AIVL office on ph: (02) 6279 1600 or email at: anniem@aivl.org.au or drop us a note by using the feedback facility on the AIVL website: www.aivl.org.au

Talk to your local NSP — next time you go to the NSP to get some clean fits ask the NSP worker about retractable needles and syringes. Ask them if your local outlet is intending to participate in the pilot studies of retractables. Talk with them about how you think the pilots should be run.

Speak with Other Drug Users — this is probably the most important of all the things you could do. We need more drug users to be aware of what the government is planning in relation to retractable needles and syringes and we need more drug users to be speaking up about what they think about them. If you can get copies of the Junkmail article you could circulate that to your mates or otherwise just talk with people about what you think of retractable needles and syringes.

Write to your Health Minister — if you are concerned, as AIVL is, about the

...AIVL stressed that it had a

responsibility to inform and

consult with its member organi-

sations and injecting drug

users on devel-opments in rela-

tion to retract-able needles and

syringes...

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Prior to the late 1800’s goods including medicines were traded openly. This included many of what are now illegal substances such as cannabis, opium and cocaine. These were usually marketed in patent medicines. There was at that time no control over who could market or purchase medicines, what they could put in them or the claims that were made about their effectiveness.

An unlimited array of products were collected, transported and marketed without impediment. Colonial powers sailed the world often harnessing exotic products from exclusive sources providing market advantage and the potential for large profits. In a world of poorly developed medical responses or access to doctors, prior to a disease model of medicine or the discovery of penicillin, patent medicine ruled supreme. Some were carefully concocted and tested products and others were frauds.

It was the potential profit and power that led to intense competition between colonial

nations for increased control of seas ports and lands. A competition between colonial powers that often led them to war with one another as well as

the wars waged against subjugated peoples.

Competition extended to the use of military pres-sure to force countries to open their markets to trade.

The most infamous example being the blockade of Hong Kong. Forcing China at cannon point to open its ports to trade with British, Portuguese, Dutch and French traders. The Chinese emperor was

resisting trading with the outside world. This was in part because they didn’t believe there was anything to benefit from this trade. There were many products of China that the Europeans were interested in trading. In exchange the British in particular offered opium, grown in India.

This trade was sponsored by organisations such as the British East India Company. A private trading

company that had as many men under arms as any sover-eign nation in the world. Though acting with support of

the British government, this was in effect a private army of a colonial investment company that oper-

ated for profit and without much in the way of control.

The introduction of opium to China had a devas-tating impact on the population. This open trade in opium increased after the forced opening to trade and the 150 year lease on Hong Kong and

surrounding territories as free trade zones for colonial powers

extracted from the Chinese at the barrel of a cannon.

Indian Opium was traded with the Chinese for consumer goods, paper, timber, crafts and gold which were highly

valued in Europe. As well as opium, other exotic plants from the new world, Asia and the Middle East were brought into European

markets. These included new food plants and spices but also cannabis and coca.

At that time there was no control over the import, labelling, and marketing of products, though goods were often taxed by govern-ments as they passed through ports. So apart from financial limitations there were no barriers to anyone buying these medicinal products over the counter and without prescription.

The capacity of unscrupulous traders to exploit vulnerable popula-tions led to the earliest controls over products. This was largely limited to their labelling in order to avoid fraud and to warn of

A brief history of drug policy in Australia.Its local and global influences and outcomes.O r ‘How the hell did we get into this

2�

rug policy in Australia has not developed in a vacuum. It hasn’t even developed through a careful scientific evaluation of our policy choices and the impacts of those choices. It has been directly influenced by accidents of history, moral certitude, racism and international relations. This is the story of how Australia’s ‘unique’ approach to drug policy has developed...D

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potential danger of accidental poisoning.

Australia’s earliest laws about these products therefore were either taxation or labelling. These followed the British examples and trends where labelling laws were to ensure that what was inside the bottle was on the label on the outside of the bottle. At this time heroin and cocaine had not been synthesised into their molecular forms and so medicines often contained extracts of coca, opium or cannabis, usually in a tincture with alcohol. Laudanum, opium solu-tions in alcohol and cannabis tinctures were selling like hotcakes in Britain. This was also the practice in Australia.

In addition to calls to standardise labelling and to extract taxes on imported goods in the USA there was at this time a movement to restrict the production, sale and availability of spirit alcohol. This temperance movement was given considerable support from some of the church and welfare associations and by the burgeoning women’s movement and other groups.

This bold social experiment, to ban a particular substance or formulation of a substance and so improve society socially, spiritually and morally was given force and impetuous by arguments that it was often the poor and downtrodden and their families who suffered from the sale of spirit alcohol. Families’

incomes were spent at taverns, their nutrition suffered, as did their capacity to work. Spirit alcohol was also held responsible

for lowering of moral standards, to cause adverse health effects and to people turning away from their churches and families and a general weakening of the social fabric.

It must be remembered that many of the spirit alcohols available at the time, especially to the poor and marginalised citizens of the US were dubious preparations sold without quality control to

maximise profit and with little control or regard for public health. Prohibitionists argued that the distil-

lation of spirits and hard liquor was too difficult to tax and regulate and that its impact on the population too stark to consider alternatives to a total ban. As the unregulated and uncontrolled marketing of

spirits was seen as having drastic health and social conse-

quences in the US so the forced open trade in opium was having an adverse consequence in China.

The Chinese method of smoking opium was a different formulation to the tinctures and tonics favoured as opium products in the west. The opium den was a source of fear and loathing among xenophobic westerners, while Thomas de Quincy, author of ‘Confessions of an English opium Eater’ was easily able to obtain and consume opium in a number of formulations in pills or tinctures.

The prohibition of spirits in America was a failure in the long term. It led to the growth of organised criminal activity in the production and sale of so called “hard liquor”. With increased profits secretive organisations became armed criminal gangs protecting product, patches and profits. When Al Capone was eventually called to account under the law it was not for the violent crime or breach of prohibition laws that he was charged but offences against the tax act due to the immense profits to be made from the sale of spirits in a prohibition environment. The decline of prohibition at the national level in the US handed back to the states and counties the rights to regulate and tax spirit alcohol. Some counties in some states of the USA still prohibit the sale and consumption of alcohol to this very day.

In Australia the first drug control laws included the labelling of patent medicines under the Poisons Act. This was to prevent the accidental overdose or poisoning associated with some products in the interests of public health. Otherwise the first drug control law in Australia was a South Australian law, made in 1895, to prohibit the sale of smokable opium to Chinese and Aboriginals. These racist laws did not affect the availability of opium, cannabis and cocaine in other forms and were distinctly targeted at populations feared by ‘white Australia’. The importation of opium in other forms continued up

until its total ban in the 1950’s.

Even at this early stage the controller general of customs for the Commonwealth

of Australia complained that the law was ineffec-

tive in preventing the importation of opium for smoking

and that the only significant impact was the loss of 60,000 pounds in import duty.

In 1908 shifting allegiances brought the interests of

the USA and China into alignment. This lead to the first international convention on the control of cocaine, cannabis and

opium under the misnamed International Convention on the Control of Narcotics. Misnamed because cannabis is not classified as a narcotic. Australia signed

Graphics reproduced from “The Pursuit of Oblivion: A Social History of Drugs”

up to these conventions on the tail of the British with little or no consideration as to the actual use and impact of these substances in Australia.

As the 1900’s progressed the international conventions were refined with increasing medicalisation. In 1924 the convention was altered so that signatory states would limit the import, sale, distribu-tion export and use of medical opium, cocaine, morphine, Indian Hemp and heroin to “exclusively scientific and medical purposes ”. These conventions have continued to evolve into increasingly strict controls of what nations and states are able to legislate in regard to drugs.

In 1953 the Federal Government of Australia banned the importation and production of heroin despite objections from the states and the medical profession. Its impact was immediate with many people who had maintained successful lives while under medically prescribed heroin being observed to suffer deterioration in their health, happi-ness and social integration.

The prohibition of substances such as heroin built on laws that banned substances because they were

foreign, seen as bad because they were illegal and viewed drug users ‘evil’ or ‘sick’ because they partook of these (newly) illegal substances. This cyclic argument

ignores the fact that the use of the substances predated the changes

to the law and that the adverse consequences experienced

by dependent users when their substance of

choice was removed from the market were different

in nature to the conse-

quences of the use of the drug per se.

Initially Australia blindly followed the British Commonwealth and later the USA in

spite of a failed history of alcohol prohibition

and the experi-ence of an

expanding and increasingly violent black market. The black market further exploited the user who was left vulnerable to unlabelled substances of unknown purity or content available at untaxed but highly inflated black market prices.

Individual countries and states within countries were left to interpret the inter-national conventions for their own legal structure and social situation. Thus many countries or states within countries retained the ability to provide heroin by prescription, to alter the level of legal sanction for a breach of prohibition depending on the substance, quantity or context. The international conventions on narcotics were revised and redrafted in 1967 under what became known as the Single Convention.

Market forces, demand, black market and production, distribution and consumption of the now illicit drugs e st a b l i s h e d conflict with the laws from the m o m e n t they were put in place. The fashions and patterns of drug usage have varied between

c o u n - tries and classes over t i m e . Enforcement

of prohi- bition has required

considerable social investment in police courts

and prisons. Treating people who have devel-

oped dependencies has required investment in

medical and treatment services. Crime associated

with the black market and to support inflated

drug prices costs society at large.

Drug users pay above

all others with their liberty, risks to their health, the discrimination

they face and the lives lost in what has become a n unregulated, uncontrolled and over inflated market.

The impact has been greatest of all on those already marginalised or poor within the society. Society has surrendered much in taxes

and much in civil liberties as the enforcement of prohibition demands increasing powers for the policing state to stop, search, and incarcerate people for what was once not a criminal behaviour but a health and social

issue. In extreme cases these include extra judicial killing as seen this year by the Thai police with over 3000 deaths in the Thai Prime Minister’s latest war on drugs.

As enforcement increased, centres for production and cultivation of drugs

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Graphics reproduced from “The Pursuit of Oblivion: A Social History of Drugs”

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moved increasingly to isolated and impoverished locations increasingly protected by the force of arms in what amounts to private armies funded by illicit cash. In many countries there are areas not under government control. Whether it is a cupboard of a suburban home where cannabis is cultivated under lights or whole areas of countries such as Afghanistan, Columbia or Burma. Through prohibition societies have also tried to control the minds and behaviours of citizens and to make drug users victims of an otherwise victimless vice.

Countries have also had their systems of law distorted by the large quantities of funds available through the black market as was seen in the Iran-Contra Arms Deal in the US or the corruption seen in police services the world over. Australia’s cannabis market is about the same size as our wine industry.

In Australia in 1985 the then Health Minister, Dr Neal Blewett, coordinated a review of the country’s response to all drugs including alcohol. This review recognised that legal drugs make up 98 percent of the deaths and disability arising from Australia’s indulgence. This review resulted in a new policy approach that brought legal and illegal drugs together and sought to reduce harm as the measurable aim of policy and expenditure. Access to treatment for all drugs was increased, labelling of legal drugs was increased and warn-ings included. Education on the risks associated with each type of drug were promoted, options and opportunities for treatment were increased.

The harm reduction strategy attempted to focus resources on realistic, measurable and achievable goals. Unfortunately the legal status of drugs was not up for debate at this stage although in the intervening years many states have softened their retaliation to cannabis users. With the expan-sion of the HIV/AIDS epidemic, harm reduction provided a philosophical framework in which needle and syringe exchange and peer based drug user

education were easily integrated. These programs have been a major success in Australia’s response to the epidemic in health, human and economic terms.

In other parts of the world different policy approaches have been taken. Policy in relation to drugs as to other aspects of society is a dynamic process, which continually evolves in response to history, circumstance, popular sentiment and context. Policies can change at the legislative level, changes to the law, but also at the level of implementation and prioritisation of the laws.

In the Netherlands, cannabis possession is illegal. However people will not be charged with an offence unless they create a disruption to the social order or if they are dealing in larger than personal quantities of cannabis. It is interesting to note that the cannabis coffee shops of Holland may have to alter their tradi-tional practices because smoking of any substance including tobacco is coming under increasing regulatory control. It is also interesting to note that although cannabis use is tolerated in the Netherlands, fewer Dutch people consume cannabis than Australians, Americans or Brits.

In the USA the “war on drugs” has denied an appropriate and effective response to the HIV/AIDS epidemic. The mandatory sentencing has seen counties; states and the nation incarcerate record numbers of its citizens. The costs of incarcerating more of its citizens than any other country in the world is crippling the budgets in some areas with prisons absorbing funds that would otherwise be invested in health, education and housing. In contrast to the US approach, a number of other countries including Switzerland, the UK, the Netherlands and Germany among others have successfully trialled the provi-sion of heroin to opiate dependent persons.

There are many ways in which Australia could improve its drug policy response. Better targeted and supported treatment options, anti-discrimination legisla-tion or the removal of drug use from the criminal justice system

Reproduced from “The Pursuit of Oblivion: A Social History of Drugs”

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Over the past few years AIVL has been monitoring the growing interest and concern of the impact of psychos-timulant use across Australia. We noted that the primary response to psychostimulant use was hysteria, resulting in the demonisation of psychostimulant users and the drugs themselves. Much of the debate taking place has been to reinforce outlandish stereotypes with little focus being attributed to the health and human rights of psychostimulant users. So to redress this balance, AIVL did a national snap shot survey of the hepatitis C transmission risks amongst injecting psychostimulant users across Australia.

It has been a great project that included all of our member organisations - the state and territory drug user organisations. We employed peer interviewers who did a fantastic job interviewing in total 182 male and female methamphetamine injectors across the country. Peers did it all, developed the snap shot questionnaire; trained the interviewers; completed the questionnaires and wrote the final report. We must however not take all of

the credit. We did have some help from a small select group of professionals who know their stuff and understand user’s issues. The project has helped us to understand in more detail the important reality for methamphetamine injec-tors and plan AIVL’s future work on this issue.

The full report from the project has recently been released, but given how much we love our JUNKMAIL readers we thought we would give you a quick look at some of the key issues from the report. These include:

• Most people had somewhere to live and over half of participants have access to the internet - this is great news and we will be developing our website over the coming two years to make it as interesting and valuable as possible. To have a look at what we have done so far go to: www.aivl.org.au;

• Not everyone is really clear on what hepatitis C is, there are some really mixed messages out there — we have a bit of a problem here, some people are doing things that are risky for hepatitis C transmission and do not know it;

• A few users had been to prison and had shared injecting equipment — not too much of a surprise here and even less so, is that methamphetamine users like using heroin when inside;

i s not a new drug or a guide to tweaking. It is the excellent peer owned project that AIVL has just completed looking at the hepatitis C transmission risks amongst methamphetamine injectors. If you’d like to

know more then read on and all will be revealed...

PSU

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• Methamphetamine users also like alcohol, cannabis, ecstasy, heroin, methadone and benzodiazepines — what goes up must come down!!!

• Sometimes a small number of users chose not to inject and

decide to smoke, chase or swallow instead. However, most users injected every couple of days - when they didn’t inject this was largely due to circumstance such as no fits or using with non injectors;

• Most users self teach or are taught to inject by a friend — peer networks are still the most important way users get information and skills;

• Access to sterile injecting equipment is not too much of a hassle but can be at times — opening hours, cost and confidentiality were raised as issues;

• Too many users have injected pre-prepared syringes of metham-phetamine and do not watch the preparation — this is a concern in relation to the transmission of hepatitis C;

• Some people are sharing their injecting equipment and this tends

to be with partners and friends — most people think that this is safe, guess what? It’s not!!!!

• Methamphetamine users tend not to use alone and use with friends — not surprising really climbing the walls and talking to yourself can be really boring;

• Blue lights in public spaces where people inject seemed to pose little if any problems for anybody. This is bad news for local councils who have spent a fortune installing them;

• Disposal of used injecting equipment is a bit of a problem, a few users told us that they are having to dispose into full containers and even have to rummage around in old fitpack containers and bags of used injecting equipment to find sterile fits and in doing so are touching used equipment and paraphernalia;

• Not that it’s any surprise but methamphetamine users surveyed said they stay up on average for a couple of days or so at a time;

• The top four activities for methamphetamine users while speeding were: watching TV, having sex, listening to music and housework — we think this kind of shatters the ‘psycho’ stereotype;

• What do users want - drug law reform, quality control, increased/easier drug availability, increased easier NSP availability and a safer injecting environment;

• Users rarely wash their hands before mixing up, after injecting or after cleaning up - this is a real issue in relation to hepatitis C transmission particularly when people are also injecting others at the same time;

• Finally, methamphetamine users think that they know about hepatitis C and are using safely and sadly this is not the case — we saw lots of risky practice across the country.

So what are we going to do with all of this information? Well, the Education and Policy Programs will be advocating and developing resources that tackle some of the key issues that arose from the snap shot. Over the next two years we will be, amongst other things, advocating on behalf of methamphetamine users and developing some excellent education resources. We will keep you posted on what and when we are doing specific activities. In the mean time we will be sending out the final report from this project to as many people and organisa-tions as possible to highlight methamphetamine injector’s issues.

Want to know more about this project? You can get a copy of the full report by either contacting your state or territory drug user organisation (details are on the back cover) or by contacting Nicky, AIVL’s Policy Officer on 02 6279 1600 or by email nickyb@aivl.org.au. The report will also be on the AIVL website

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One of the great things about where drug user activism is at the moment is the strong links existing and being constantly developed between drug users who are fighting for users’ rights and law reform in many different countries in every corner of the planet.

We know that while one country may make gains — many of which, like widespread needle and syringe access, do make a crucial differ-ence to the health and happiness of our user communities, and are certainly very much worth fighting for, there is an international system of prohibition and drug user oppression. This system is pushed constantly by the US and facilitated by the United Nations; it seeks to stomp on reform agendas, and frequently succeeds.

Up until now, many of the links between individual campaigners and user organisations around the world have been based around email

groups and websites. Email and the internet have greatly assisted many grass-roots movements to share experiences; for us it has also provided the chance to offer mutual support and solidarity, and coordinate user presence and representation at international conferences. Many user activ-ists are currently committing ourselves to the development of an international drug user rights organisation which can start to challenge and break-down the US dominance over drug law and policy. There is a good chance that the founding conference of this group will be held prior to or following next year’s International Harm Reduction Conference, which is being held in Melbourne.

Some of the hardest decisions that might be faced by this new organisation are where, and towards what issues, we should dedicate our resources and energies. Because as we make contact with more users in more countries, we become exposed to more and more violations of users’ basic human rights, the denial of basic human dignities, and, in more and more horrible cases the

he production, supply and use of illicit drugs is a global phenomenon — so too are the efforts to control them. In the spirit of the international theme for this issue of Junkmail, this article looks a little closer at some of the human rights violations and attacks currently being perpetrated against citizens in a number of countries in the name of prohibition. In

this

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denial of life altogether — most prominently the deaths of over 2000 drug users in Thailand (and their family members).

It is up to us as drug users to highlight and protest these atrocities. No one else will do it for us. It is all too clear that many ‘human rights advocacy organisations’ must consider drug users to be sub-human; they stand silent while drug users are subjected to some of the grossest human rights violations taking place on the planet.

Where are these violations taking place, and what is life like for our using brothers and sisters who are forced to endure them? The first case has been fairly well covered by ‘mainstream’ media outlets, but no matter how many articles I read on the subject, I continue to be shocked and nauseated by the scale of the attack on drug users.

China’s Annual Day of Death ‘’And welcome again, ladies and gentleman to our latest and greatest attempt to distract you from real problems through the

demonisation of a disempowered, disenfranchised community group. It’s June 26 again, and of course time for the annual United

Nations-designated International Day Against Drug Abuse & Illicit Trafficking. Over the last few years the Chinese Government has developed a standard way of marking the day with public executions of ‘drug dealers’. The preferred method of execution - a bullet through the back of the head! Sixty four people eliminated in 2002 alone!

This main attraction to the base aspects of our human nature is supported by a great Sideshow Alley. Roll right up for the public humiliation spectacle as we see those convicted of drug crimes led away to spend life-sentences in labour and re-education camps. The south-western city of Chengdu, has also introduced the burning of seized drugs at rallies with 1000s of people in attendance. Just don’t breathe in, ladies & gentleman!”

And what is the stance of the UN towards their international day being the trigger for an annual Day of Death? They “do not condone it” (Dallas Morning News, 27/6/02). Strong stuff! The Chinese administration must be really scared!

Thailand Death SquadsIn late January the Prime Minister of Thailand, Thaksin Shinawatra, announced an intention to “rid every square inch of the country of drugs”. (From Straits Times, 16/1/03). Since that time an estimated 2000 Thai citizens have been executed in situations linked to the resulting war on drugs. While the Thai government claims responsibility for only a handful of these deaths, and blame the remainder on rivalry between drug dealing networks, many of the deaths carry the hallmarks of government death squads, with similar ammunition and modus operandi being used in many of the executions.

A number of children have been caught up in the killings, including a one-year old boy murdered in an incident that injured his mother, and the shooting of 9 year-old Chakkapan Srisa-ard, for which several police are now awaiting trial. (The Scotsman, 25/2/03)

Even in those cases where government involvement is not suspected, the atmosphere of murder and the devaluing of the lives of drug users is creating an environment where killing is acceptable.

In addition to the deaths, 41000 Thai citizens have been placed on ‘monitoring lists.’ The government has been unwilling to reveal the sources from which this list was created. In some areas whole villages appear on these lists, and are often raided in the middle of the night. Many of these raids, such as one recently shown by the ABC’s Foreign Correspondent program, do not turn up any drugs whatsoever.

Tens of thousands of Thai drug users have been sent to ‘detoxification’ camps without the right to trial. The Thai government simply does not have the resources to conduct detoxification programs for that many dependent users in anything resembling a humane fashion.

At one such camp, run by Buddhist monks of the Wat Worachet temple, users

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were kept chained by both their hand and their feet, 24-hours a day for nearly a month. (See the international news on 12 page.)

AIVL has stated our belief that the state-sponsored execution of citizens, the surveillance and monitoring of others, and imprison-ment in concentration-camp environments without the right to legal recourse constitutes one of the most extensive and systematic violation of human rights taking place in the world today. We are working with the Thai Drug Users’ Network to protest and address these injustices.

‘Plan Columbia’For the purposes of analysing the current strategy being pursued by the US administration, lets call the events that have been occur-ring in Thailand as a ‘micro-war’ — not because its minor in scope or because 3000 deaths is an insignificant body count, but because it is being carried out by small, officially unsanctioned paramilitary units, and it is targeted at the most vulnerable, at drug war ‘non-combatants’ — users and user-dealers. In comparison, let’s call Plan Columbia — the US vision for attacking the drug trade in South American nations — a ‘macro-war.’

The political situation between the two countries is, of course, remarkably different. But by looking at the two together, we can

start to see the ways in which the US is experimenting with different, equally brutal means of gaining total dominance and eliminating opposition. Where Thailand sends out paramilitary death-squads of a half-dozen, the US trains and equips real military units numbering in the hundreds for the Columbians.

Where a .11 millimetre pistol is the weapon of choice in Thailand, the Columbians have decided on the Apache helicopter gunship, and machine-guns for soldiers on the ground. Aerial spraying of coca planta-tions using Glyphosate, a product made by Montsanto (the company that made the Agent Orange defoliant that devastated Vietnam) has killed staple crops like bananas, rubber, cocoa and yuca, as well as damaging the health of peasant families through polluted waterways and fisheries. Many of these crops have been grown in the same area, by generation after generation of the same peasant families, for centuries. Coca use has been a traditional part of these people’s lifestyle for just as long.

If we look at the way Plan Columbia’s finances are allocated, we can see where their real commitments lie. Of around US$5 billion, only around $250 million — 5 percent- is allocated to incentives designed to encourage Columbian peasants to shift their agricultural efforts from growing coca to growing food crops like corn. The average family growing coca earns around 10 times more each year than a family growing a food crop, and still they only just scrape over the poverty line.

‘The Swedish Sideshow - Sex, Snow and the Slammer for Substance-Users!’ Sweden is often held up as a progressive, people-friendly place to be: a good welfare system, accessible health-care, maternity leave and child-care, and lots of sexy Scandinavians screwing in the snow. And this image is basically accu-rate - unless you happen to be a drug user, especially a young one.

Undercover police officers frequently ‘trawl’ nightclubs and bars; if they believe, through observation alone that a group or individual has been using any illicit substance — the cop does not need to search them for drugs, or even see them being taken - they can be taken into custody and forced to submit to urine screens. ‘Detected’ results will result in criminal charges and a court appearance — the police have no discretionary powers to let someone off with a warning.

The Swedish try to sell their policies as being humane. Although we have zero tolerance, we are not repressive. “People are not thrown into prison for smoking cannabis, only if they have committed other crimes along with it,” states Tomas Hallberg of European Cities Against Drugs. So if these now-convicted young users aren’t sent to prison where do they go? To rehabilitation. Are they free to leave if they decide it’s not for them? Of course not! Are they given any medi-cation to ease withdrawal symptoms? You’ve got to be joking.

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What do you call a place where you are held irrespective of your wishes for up to a year? I call it prison. In fact, with the absence of medication, the mandatory counselling, the Christian sing-alongs, I think many ‘residents’ would be hoping for some solitary confine-ment. While incredible resources are poured into taking the choice to use drugs away from the people who want to make it, older users seeking assistance with their use (‘treatment’) can find it difficult to come by, and then do not have the even limited options we do here — there are only 650 places on methadone programs for the entire country.

The Swedish model has been held in high esteem by many govern-ments but have they really looked into the Swedish approach in detail? They usually take as their starting point for judging the success of a policy not on the health or happiness of a population, but whether it is ‘drug-free’ or not. It is true that the percentage of the overall population that has sampled illicit drugs is considerably lower in Sweden (about 9%) than in most other European nations (about 30%) and Australia.

On the flip side, according to a report by a European Community drug agency, Sweden has among the highest drug-related death rates in Europe and the highest rate of hepatitis C among people

injecting heroin. It’s been said that the success of a country’s healthcare, welfare systems and civil liberties can be judged by how available they are to the most vulnerable and dispossessed elements of that community and by how those individuals are treated within those systems. Until Sweden comes to grips with the reality of drug use there will remain a very dirty blotch on their ‘welfare-state record’.

Good Old USA!‘Ride the Ghost Train into the belly of the beast itself. Splash down in a place with the kinds of social attitudes you thought the world had done away with years ago. Welcome, folks, to Old America Town (as it really was in 2003)!’

Never let it be said that the US is only promoting its drug war agenda overseas. In the belly of the beast, illicit drug users are facing some of the most backward legal and ‘health’ regimes seen anywhere in the world.

Let’s start with some horrible statistics — possibly the most horrible of which is the rate at which the US imprisons its citizens. It has the highest rate of imprisonment in the world, with drug users bearing a large part of the burden. This is from an editorial in the New York Times, April 4 2003. “The population of the nation’s jails and prisons passed two million last year, for the first time in history. The United States has one of the highest incarceration rates in the world, and

one that falls unevenly. An estimated 12 percent of African-American males between 20 and 34 are behind bars, more than seven times the rate for white men the same age. The number of men and women behind bars today is four times what it was in the mid-1970’s, and it continues to grow. This soaring incarceration rate is not tied to the violent crime rate, which is lower than it was in 1974. Nearly 60 percent of federal prisoners and more than 20 percent of state inmates are in custody on drug charges, in many cases low-level ones.”

Drug prohibition was given birth in an atmosphere of racism, and its use in keeping black and Hispanic populations powerless, poor and imprisoned has only increased since that time. One of the most blatantly racist aspects of drug-war US-style is the difference in the imposition of mandatory minimum sentences for crack cocaine, used overwhelmingly by blacks and Hispanics, whereas there are no mandatory minimums attached to the use of powder cocaine, a form of the drug more popular in white communities. In 1986, before mandatory minimums for crack offences became effective, the average federal drug offence sentence for blacks was 11 percent longer than for whites. Four years later following the implementation of harsher drug sentencing laws, the average federal drug offence sentence was 49 percent longer for blacks. Beyond prison walls, the situation for poor drug users is equally bleak.

A particularly offensive weapon in the war is the sterilisation of drug users.

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Children Requiring A Caring Kommunity (CRACK) ‘offers’ drug users $200 if they are willing to undergo tubal ligations, vasecto-mies, or long-term Depo-Provera treatment. Obviously, the only users likely to succumb to this type of campaign are those in the most desperate need of cash — the poor and dispossessed. The CRACK campaign amounts to a ‘eugenics’ program — it is, intentionally or otherwise, attempting to ‘purify’ America through only allowing a particular section of the commu-nity to reproduce. Despite a number of open letters signed by up to 100 prominent doctors, paediatricians, and NGOS, and innumerable

physical protests, CRACK continues to expand its activities, and this year launched in New York City.

In a media release promoting an anti-CRACK protest, the executive director of National Advocates for Pregnant Women based in New York, Lynn Paltrow, stated. “We support contra-ception and birth control services. But we also believe that targeting any one group of people for those services is simply un-American.” Furthermore, Paltrow pointed out, “The greatest threat to children in America today is not drugs and it is not their parents who may or may not use drugs. It is that millions of hardworking families who don’t have access to health care, housing, and drug treatment” The release continued: “Ashanti Alston, from the New York chapter of Critical Resistance, points out that CRACK has a history of targeting communities of colour and poor people, as evidenced in their past placement of ads and billboards in poor neighbourhoods and in their Seattle program’s advice to target people who go to soup kitchens.” CRACK’s has also announced that they are contacting probation/parole depart-ments and jails where a high percentage of inmates are people of colour. Alston commented

that, “Linking CRACK ‘s cash-for-sterilization program to public officials who have the power to decide whether or not someone goes back to jail creates a level of government involvement in reproductive choice that is both immoral and illegal under the US Constitution.”

In addition to having to deal with the images promoted by groups like CRACK, many women are now facing criminal charges for using drugs while pregnant. In the 2001 criminal case ‘State Vs Regina

McKnight’, a jury took ten minutes to convict Ms McKnight of ‘homicide by child abuse’ after her child was still-born, supposedly as the result of Ms McKnight’s drug use. The only evidence tended to prove this was that there was a cocaine by-product discovered in the child’s blood during post-mortem. Ms McKnight received a sentence of 20 years imprisonment, with a minimum non-parole period of 12 years. The sentence is currently under appeal.

But it doesn’t stop at the removal of drug using women’s rights over their own bodies; many states now automatically assume a newborn is suffering criminal neglect if there is evidence of the mother being a drug user; returning a ‘detected’ during a drug screen — which can be conducted along with other medical tests without the mother’s knowledge or consent — can be sufficient cause for the removal of children. In fact, a mother’s cigarette smoking has been shown to have far more serious health effects on both the unborn foetus and the newborn child as compared to cocaine use.

I spend quite a bit of time on a worldwide drug issues discussion board called www.bluelight.nu. Beyond all the statistics, one thing I pick up again and again from American drug users is a deeper and more intense sense of shame and self-loathing than is generally seen here. Where users here may come into contact with a whole range of different programs and ideas in relation to use — from user rights magazines, maintenance programs, right through to mate-rials promoting abstinence - the Narcotics Anonymous 12-Step Program is very much the dominant idea that users accessing services in the States will be confronted with. Many Australian users are exposed to ideas that encourage us to be in control of our use, to know how much we are taking, to learn to inject ourselves; the 12-Steps preach that we are all out of control and have to hand responsibility for our existence over to a higher power. Add to the guilt laid down on that trip a constant anti-user media barrage. A media campaign released shortly after the terrorist attacks on New York tried to link buying drugs in downtown Detroit — or any US city or suburb - with the financial operation of al-Qaeda and other terrorist cells. “Where do terrorists get their money?” asks one of the ads, which portrays a terrorist buying explosives, weapons and fake passports. “If you buy drugs, some of it might come from you.”

In actual fact, it is prohibition and the drug war which has created the environ-ment where significant proportions of drug production and distribution takes place in isolated areas backed by the finance of organised crime and terrorist groups. In what other parts of the economy are the consumers held to blame for the actions of the producers — particularly where there may be as much as ten-steps of separation between the producer and your street-level supplier.

Don’t get me wrong, there are some great drug user activists and genuine non-user supporters of law reform. Much of the work I do in terms of monitoring the state of the international drug war is facilitated by the websites of the group Common Sense for Drug Policy at www.csdp.org. The sites feature very extensive research into the real costs of prohibition. The Media Awareness Project at www.mapinc.org relies on dozens of volunteers around the world to monitor their local media sources and they then post these articles and radio

...Drug prohi-bition was

given birth in an atmosphere

of racism, and its use in

keeping black and Hispanic populations

powerless, poor and

imprisoned has only

increased since that

time...

JUNKMAIL #6 �0

Tooting and Hep C: Latest StudyRecently new US research has been released showing a link between sharing tooting (snorting) paraphernalia and straws and the transmission of hep C. People snorting their drugs should remember that dollar notes, etc, are more than likely to have already been up someone else’s hooter (nose) and hep C is a resilient virus...

Do not share tooting equipment!!! While in the past research showed that 4.7 percent of users surveyed admitted to sharing tooting equipment recent research shows the figure is closer to 10 percent (although some believe the 10 percent figure could be inflated by people with hep C who are reluctant to admit to needle sharing).

Another health tip for tooters and sniffers is that latest research has established a clear link between Sinusitis and Chronic Fatigue Syndrome (CFS) in a significant number of sufferers.

Every time you toot you will do some damage to your nasal membranes and sinuses. Chronic ingestion by this means risks creating an excellent pathway into the body for opportunistic infections (including Strep A which lives in this area).

Take care of your hooters. Do not flush with nasal sprays, as they do more harm than good. Rinse with warm salt water and if you develop infections in the sinus regions get treatment!! These infections can become deep rooted, resistant to treatment and antibiotics and acutely painful.

A limited number of antibiotics are effective due to the difficulty of delivery to this region and infections can get into the bone and nerve pathways from the mouth and teeth. If CFS develops this is a chronic, debilitating condition, difficult to diagnose and especially difficult to get diagnosed if you are a known drug user.

This info was provided by AIVL’s friends in the U.S.

Hepatitis C Research Project at Turning Point Alcohol and Drug Centre, Fitzroy. Research Summary 2003A team of researchers from Turning Point Alcohol and Drug Centre recently conducted a study to design and evaluate an intervention for reducing individual risk behaviours associated with the spread of hepatitis C. This research came about to address the continuing problem that hep C poses to the injecting community. Public health initiatives such as Needle and Syringe Programs have significantly limited the spread of HIV among injecting drug users, however they have had less of an effect on reducing the incidence of hep C. One way that we may be able to reduce the spread of hep C is to focus upon achieving a reduction in the injecting and other risk behaviours associated with its spread.

The aim of this study was to look at new ways of giving users information about hep C that would hopefully lead to changes in injecting and other risk practices, and ultimately lead to a reduction in HCV spread. To do this, each participant’s hep C risk behaviour was measured using a questionnaire called the BBV-TRAQ. Each participant was then either given some current hep C pamphlets (from VIVAIDS, AIVL, HCV Council) to take home and read or had a 30-minute information session with a Turning Point worker. This type of information session is known as a brief behavioural intervention. These have been used with some success in reducing substance misuse in other settings. The scientific literature suggests that brief behavioural interventions are an extremely effective method of producing changes in behaviour in a short period of time. As well as giving more information about risk practices, the brief behavioural intervention encourages people to develop strategies to reduce the problematic behaviour and addresses barriers they have to changing these behaviours. This is important, as we know that it is the context in which risk practices exist which has an important impact on that risk.

JUNKMAIL #6 �1

One month after the initial interview all participants were asked to return for a second interview. Participant’s hep C risk behaviour was measured again by the same questionnaire that was used in the first interview. In total 145 people took part in the study. 72 people were given pamphlets and 73 had the brief behavioural intervention. Of those people, 124 returned for their second interview. BBV-TRAQ scores for the people who completed both components of the study were then compared to determine what change had occurred over time. By looking at the initial BBV-TRAQ score and the BBV-TRAQ score taken at follow up and comparing these between both groups, we were able to examine the effect of how the information was presented on any changes people made to their risk behaviours.

Overall, the results showed that people who took part in the research reduced their risk behaviours associated with hep C from the first interview to the second one. However, when the amount of change was compared between the group who received the pamphlets and the group who received the brief behavioural inter-vention each groups’ reduction in risk behaviours was almost the same. This finding suggests that both the pamphlets and the brief behavioural intervention were equally effective in reducing risk behaviours associated with the spread of hep C.

Another explanation for the findings is that because the BBV-TRAQ asks very specific and detailed questions about risk practices, it could have also produced a reduction in risk behaviours because it makes people think about their risk behaviours - a similar effect to the brief behavioural intervention. Future research is planned to investigate the utility of the BBV-TRAQ as a therapeutic tool and the potential for it to be used in a peer counselling setting.

These findings are very important because reducing risk behaviours associated with the spread of hep C will hopefully translate into a reduction in the number of new infections.

Thank you to those of you who took part in this research project, your assistance is invaluable. If you would like a more detailed account of this research project or have any questions, please contact Craig Fry, Senior Research Fellow, Turning Point Alcohol and Drug Centre, Melbourne at craigf@turningpoint.org.au or (03) 8413 8413.

by Craig Fry

Methadone Metabolisation and Dosing — Do Some People Need Higher Doses of Daily Methadone due to Faster

Metabolisation?For many years, some people on methadone have complained about needing higher or split doses because they metabolise their dose faster than others. While some prescribers have been responsive to such requests, many people have been treated as if it is either ‘all in their minds’ or they are simply ‘drug seeking’. In reality, people experiencing this problem live with daily withdrawal symptoms and often resort to ‘topping up’ (using another opiate on top of their methadone dose) just to feel comfortable and live a normal life. The research below from Shinderman et-al finally exposes and acknowledges the reality of this issue. AIVL encourages Junkmail readers to distribute this report as widely as possible especially to those services which routinely underdose patients...

Do some MMT patients require higher daily methadone doses because they naturally digest the drug more rapidly or extensively?

Methadone is metabolized by several enzymes of the Cytochrome P450 system, primarily in the liver by CYP3A4. A new *study examined the relationship between patients requiring different levels of daily methadone for stabilisation and the intrinsic activity of this enzyme.

Subjects at the Centre for Addictive Problems, Chicago, were selected repre-senting three methadone-dosing levels (approx. 10/group): “low” (up to 99 mg/day); “high” (100-199 mg/d); “very high” (200 mg/d and above). All were long-term patients, stabilised on methadone, and abstinent from illicit drugs.

Prior to daily methadone dosing, patients were administered midazolam. (The metabolism of this short-acting benzodiazepine serves as a marker for CYP3A4 enzyme activity.) CYP3A4 activity and methadone serum levels were assessed via blood samples sent to specially equipped laboratories in Switzerland.

Compared with the “low” dose group, patients requiring “very high” methadone doses for stabilisation had significantly 76% greater CYP3A4 enzyme activity. There also was a significant difference between the “high” and “very high” dose groups.

In a broader analysis, all patients were divided into those receiving either less than the median 110 mg/d methadone dose (mean 74 mg/d; range 20-100 mg/d) and those receiving more than 110 mg/d (mean 283 mg/d; range 120-1000 mg/d). Those in the higher-dose group had approximately 50% greater CYP3A4 activity.

This study demonstrated that there is a significant correlation between the optimal daily methadone dose required for stabilisation in MMT and the meta-bolic activity of CYP3A4. That is, as the authors concluded, many patients may require higher methadone doses than commonly administered due to a greater intrinsic activity of key enzymes that metabolise the drug.

*See: Shinderman M, Maxwell S, Brawand-Arney M, Golay KP, Baumann P, Eap CB. Cytochrome P4503A4 metabolic activity, methadone blood concentrations, and methadone doses. Drug Alcohol Dependence. In press 2002.

JUNKMAIL #6 �2

Retracted Ecstasy paper “an outrageous scandal”: Prominent scientists who raised concerns about paper now say Science should publish referees’ reports

The retraction last week of a highly controversial paper published in Science September 2002, which purported to show that the recreational drug Ecstasy (methylenedioxymethamphetamine, or MDMA) caused severe damage to dopaminergic neurons, predisposing takers to Parkinson disease, has prompted two leading British scientists to call for the journal to publish the referees’ reports.

Colin Blakemore-Professor of Physiology at Oxford University and chairman of the British Association for the Advancement of Science, who will shortly take up the position of Chief Executive of the UK Medical Research Council-and Leslie Iversen-a prominent pharmacologist who holds Professorships at King’s College London and Oxford University and reviewed the effects of cannabis for a House of Lords select committee report-both made the recommendation in interviews with The Scientist last week.

Even before the retraction, Blakemore and Iversen had been involved in a lengthy e-mail exchange about the original paper with Donald Kennedy, the editor-in-chief of Science, last year. Neither believed the paper should have been published, because of several glaring discrepancies.

The retraction came about because George Ricaurte of Johns Hopkins University, lead author of the paper in question, discovered that certain reagents had been mislabelled after further experiments had failed to reproduce the results. It turned out that the monkeys and baboons in the experiment had received methamphetamine (“speed”), a more dangerous drug that has a known effect on the dopamine system, not MDMA, which mainly affects serotonin. The reagents had been obtained through the National Institute on Drug Abuse (NIDA).

The paper claimed to demonstrate that dopaminergic neurons were damaged after MDMA doses equivalent to those typically taken recreationally by humans. In the original Science press package distributed to journalists, “damaged” was altered to “destroyed.” According to Blakemore, Kennedy told him in an e-mail exchange that this was done “after consultation with the authors.” Understandably, media reports found the release sensational and claimed a night’s clubbing could give you Parkinson disease.

Ricaurte later told a journalist that the press release “was never meant to imply that cell bodies had degenerated.” Kennedy was unavailable to comment to The Scientist, but Ginger Pinholster, director of the Office of Public Programs at the American Association for the Advancement of Science (AAAS), which publishes Science, pointed out that only one para-graph of the press release said “destroyed,” whereas all the other paragraphs said “damaged.”

“That’s true,” Blakemore told The Scientist, “but the crucial paragraph, and the one that got reproduced in press reports around the world, said ‘destroyed.’ And it’s quite clear that the authors intended that, as they point out that Parkinsonian symptoms arise when 60 to 80% of dopaminergic cells are destroyed, and say that we can therefore expect an epidemic of Parkinson’s disease.”

There were obvious weaknesses in the paper, claimed Blakemore. First, 40% of the animals given supposed MDMA at a “common recreational dose” were found to be dead or dying. “But police [in the UK] estimate that one million young people take Ecstasy each weekend, yet there are only a few deaths each year,” Blakemore told Kennedy.

Second was the question of the dose. The drug was administered subcutane-ously, which would give a much larger dose to the brain than the usual club-ber’s tablet, Iversen told The Scientist; but blood plasma levels of the drug were not measured. And third was the extreme effect on the dopamine system, which had not before been recorded for MDMA but was known for methamphetamine (the drug actually administered, as it later turned out).

The issue is no small spat, but of profound public importance, say Blakemore and Iversen. “Scientific evidence is of crucial importance in our approach to the problem of drug abuse,” Blakemore wrote to Kennedy last year, “but deliberate misrepresentation or exaggerated presentation of risk is likely to do more harm than good.”

If you are interested in the issue of heroin programs, you may want to check out this new publication from the UK written by two leading harm reductionists...

Prescribing heroin: What is the evidence? Gerry V. Stimson and Nicky Metrebian

Prescribing heroin, the first overview of how and why heroin is prescribed in the UK, brings together research evidence from the UK and elsewhere to provide a comprehensive review of its benefits and drawbacks. It will be a comprehensive guide to the subject for everyone with an interest in how we respond to heroin addiction.

Gerry Stimson is a Professor at Imperial College London, and heads the Centre for Research on Drugs and Health Behaviour. He has published widely on harm reduction, and drug policy more generally. Nicky Metrebian is a leading authority on heroin prescribing in the UK.

‘Prescribing heroin’ is the third publication from the Joseph Rowntree Foundation’s Drug and Alcohol Research Programme (previous titles are ‘Times they are a-changing’, ISBN 1 84263 062 8, and ‘A growing market’, ISBN 1 85935 084 4) and it is available free as a PDF file from http://www.jrf.org.uk/home.asp or in paperback from York Publishing Services, 64 Hallfield Road, Layerthorpe, York, England YO31 7ZQ (tel: +44 (0)1904 430033). The paper-

AIVL resouces are available free of charge to drug users through AIVL member organisations (see the AIVL directory on the facing page for details). Other services and organisations wishing to obtain bulk copies of AIVL resources should contact the AIVL national office for an order form and to arrange payment and delivery.

• See directory on the facing page for national office details •

NAME ADDRESS

POSTAL PHONE FAX E-MAIL

AIVLLevel 2, 112-116 Alinga StreetCanberra, Australian Capital Territory GPO Box 1552 Canberra ACT 2601(02) 6279 1600 (02) 6279 1610info@aivl.org.auanniem@aivl.org.au bethh@aivl.org.aujude@aivl.org.au skyej@aivl.org.aunickyb@aivl.org.au dayles@aivl.org.au

NAME ADDRESS

POSTAL PHONE FAX

SAVIVE 64 Fullarton Rd Norwood, South Australia PO Box 907 Kent Town SA 5071 (08) 8362 9299 (08) 8363 1046 manager@savive.org

USERS Assoc. SA C/- ACSA 64 Fullerton Rd Norwood, South Australia 18 Price Avenue Pennington SA 5013 0423653896 michaelmcgregor@iprimus.com.au

NAME ADDRESS

POSTAL PHONE FAX

NAP 19 Gilbert StreetLudmilla, Northern Territoryc/- Darwin GPO Darwin NT 0800(08) 8942 0570 No fax contact naptnt@bigpond.net.au

VIVAIDS 275b Smith St Collingwood, Victoria PO Box 2435 Fitzroy Vic 3065 (03) 9419 3633 (03) 9415 7055 drugsafe@vicnet.net.au

NAME ADDRESS

POSTAL PHONE FAX E-MAIL

WASUA 440-444 William St Northbridge, Western Australia PO Box 290 Maylands WA 6931 (08) 9227 7866 (08) 9227 7855 info@wasua.com.au

CAHMA G33, Griffin Centre 19 Bunda St Civic, Australian Capital Territory PO Box 78 Braddon ACT 2612 (02) 6262 5299(02) 6262 8381 cahma@apex.net.au

NAME ADDRESS

POSTAL PHONE FAX E-MAIL

DUNES 2019 Goldcoast HwyMiami, Queensland PO Box 224 Miami Qld 4220 (07) 5520 7900 (07) 5520 7344 info@dunes.org.au

TUF 155 Stuart HwyParap, Northern TerritoryPO Box 835 Parap, NT 0804 (08) 8941 2308(08) 8981 3294info@tuf.org.au

NUAA 345 Crown StSurry Hills, New South Wales PO Box 278 Darlinghurst NSW 1300 (02) 8354 7300 • 1800 644 413 (02) 8354 7350 admin@nuaa.org.au