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Never Say No

Addicts don't have to stop using drugs to get treatment in San Francisco

FRIDAY, May 4 (HealthScout) -- The city of San Francisco, already known for its groundbreaking needle-exchange programs, is now embracing a controversial philosophy that rejects abstinence as the ultimate goal of all drug treatment.

Getting people off drugs is important, proponents say, but keeping them out of trouble -- medical or otherwise -- is even better.

"The preferred goal is abstinence, but we also recognize that that is not possible for everybody," says Dr. Joshua Bamberger, the medical director for housing and urban health with the city's Department of Public Health.

But critics say one of America's most liberal cities has lost its way.

"The best message is, 'Don't touch that stuff,' " says Katherine Ford, spokeswoman for Drug Free America.

The city's new approach to drug addiction -- known as "harm reduction" -- traces its roots back about 15 years when clean-needle exchange programs were created to combat the AIDS epidemic, according to Marsha Rosenbaum, co-director of the San Francisco office of the Lindesmith Center-Drug Policy Foundation. The group supports reform of drug laws, including the legalization of marijuana.

The foundation says the promotion of safe drug use, like safe-sex education, will prevent illness and death.

"As much as we might deplore drug use, it's probably not going away," Rosenbaum says. "Rather than use our energy to try to stop the behavior, which seems futile, we instead need to focus our energies on safety and reducing the harms that can accompany drug use."

In San Francisco, harm reduction became an official city policy several months ago; officials are not aware of any other cities that have such a philosophy.

In the City by the Bay, harm reduction applies to all drug and alcohol treatment programs and is being put into place in several ways:

  • All city-supported drug treatment centers must either offer non-abstinence-based programs -- which allow participants to continue using drugs or alcohol -- or give referrals to other centers that offer such programs. No addicts who refuse to quit can be turned away without being given an alternative.

    Treatment centers have traditionally offered a "my-way-or-the-highway" approach to addicts, Bamberger says. For example, one San Francisco drug program refuses to treat addicts who used drugs the night before.

    "They literally turn their back and say we can't talk to you, leave," Bamberger says. "That's not acceptable."

  • Needle exchange centers, which have been in place for years in San Francisco, have been expanded to include medical clinics for treatment of drug-related illnesses, such as pus-filled absesses that plague users who inject drugs.

    "We're building on the first step that drug users make to provide themselves with clean needles," Bamberger says. "We can treat their health problems and teach them how not to get health problems in the future."

    Thirteen , three-hour health sessions are now offered each week for addicts, he adds.

  • Jail inmates are learning to detect drug overdoses and administer CPR. They're also learning how to prevent overdoses.

    Many addicts take large doses of drugs right after jail and suffer extreme shocks to their systems because their tolerance has lowered, Bamberger says. In some cases, they die.

  • Soon, the city will launch a pilot study to determine if addict couples should be given supplies of nalaxone, a heroin antidote, to inject into their partners if they overdose.

The city also hopes to test a new type of drug that is similar to methadone, which is already used to treat heroin addicts. Methadone, which is itself addictive, is controversial because heroin addicts sometimes trade one drug for the other, although methadone is much less harmful.

Harm reduction is "just treating drug users like we treat anyone else with a disease," Bamberger says. "We engage people and negotiate how best to get them to good health. It's not saying that drug use is good. It's just recognizing that it's there."

But Dr. Robert DuPont, former director of the National Institute on Drug Abuse, says harm-reduction programs are too easy on addicts who should be convinced to stop using drugs.

The next step could be "safe injection rooms," which have been instituted in Europe, DuPont says. The rooms -- in the Netherlands, Switzerland and Germany -- give addicts a place to "shoot up" where medical personnel are available if someone overdoses.

"It's like saying to an alcoholic about driving, 'We're going to put rubber bumpers on your car and make sure you have an extra seat belt, but we're smart enough to know that you're not going to stop driving and drinking, so we're not going to work on that,' " he adds.

Whether they are addicted to drugs or alcohol, people need to be told to stop, says DuPont, who served as White House drug czar under Presidents Nixon and Ford

"They need to have continued pressure put on to do it," he adds. "Every day that pressure is there is helping them. Every day it's taken off is hurting them."

What To Do

To read about the policies supported by the Lindesmith Center-Drug Policy Foundation, which advocates harm reduction, visit its Web site.

The Drug Free America Foundation has a very different point of view. Its Web site includes moral and spiritual reasons to avoid drug use.

A city councilwoman from Vancouver, British Columbia, visited Amsterdam, Holland, and Frankfurt, Germany, to learn about their harm-reduction drug programs. You can read her report here.

You also might want to read previous HealthScout articles on drug abuse and others on heroin.

SOURCES: Joshua Bamberger, M.D., MPH, medical director for housing and urban health, San Francisco Department of Public Health; Katherine Ford, spokeswoman, Drug Free America, St. Petersburg, Fla.; Marsha Rosenbaum, director, San Francisco office, Lindesmith Center-Drug Policy Foundation; and Robert DuPont, M.D., clinical professor of psychiatry, Georgetown Medical School, Washington D.C.
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