The First International Conference On Heroin Maintenance: Commentator Panel, David C. Lewis

Let me comment briefly on what I have heard today and also on my experience with the heroin maintenance issue in this country. I think the presentations were excellent this morning-scientifically sound, although it is a difficult clinical trail, cumbersome clinically because of the pharmacological properties of heroin, and not an easy trial to sponsor from a medical point of view. On the other hand, it is clinically relevant to the traditions of medicine, reaching out to a population in need and socially responsible.

I was interested in Dr. Uchtenhagen's comment that the police reported little, if any, trouble from their trial, virtually no complaints from neighbors. The Swiss trial was a discreet and contained project, time limited, carefully planned with a small number of addicts enrolled in the study.

The Swiss investigators had to overcome some objections; public health, medical, political, and enforcement, but nonetheless, they were able to do so. When there was a plebiscite on the project in Switzerland, the public spoke out in strong support of their project.

What was not presented was how heroin maintenance will lead to a general solution of national drug problems or how heroin maintenance will be the cutting edge of drug law reform. I believe Dr. Uchtenhagen's closing comment was that this is not the first step in the legalization of heroin, and I would say not in Switzerland and not in the United States either.

It's also clear how culturally imbedded these projects are, and in many ways need to be. This is not a project that can be exported whole. It appears that while national policies may vary, it's interesting to me that the public still favors abstinence as a treatment goal. But where these projects are occurring, that preference of the public has not been translated into a zero tolerance policy.

In both proposed and already conducted trials, I note that functional improvements as well as drug use measures are important, as they should be, to a positive outcome. Also all the projects, one way or another, were planned in conjunction with the government. I am looking to Switzerland, the Dutch and, to some extent, Australia as examples in this regard and contrast them with our experience in the United States where the government would be a less likely partner in the planning process.

I believe that this morning's presentations and discussion, were very positive in terms of moving forward in a scientific and clinical understanding of heroin maintenance issue. My own view is shaped in part by my experience with these three national projects. I had a chance to review and comment on each one of them and had a chance to visit the clinics in Switzerland at the invitation of the Swiss Federal Office of Public Health with my colleague at Brown University, Dr. Robert Swift, who is a psychiatrist and a psychopharmacologist. We saw first hand what was happening there early in the trial.

In the United States, if I reflect on the history of heroin maintenance here, there was the Vera Institute of Justice project proposed in the early seventies. That project, for which I was offered the medical directorship, was a project that was primarily intended to use heroin maintenance as a time limited transition to methadone maintenance or to the option of detoxification to drug-free treatment.

The project was approved by the City of New York, it was approved by the State of New York, and it was disapproved by the federal government. According to Herbert Sturz, who was the director of the Vera Institute at the time, he believes that the decision was made at the White House, possibly to resolve differences among federal departments at the time.

The reason I believe it was disapproved is, that it was "delivering the wrong message." But I can tell you with the city and the state approval then and the plan pretty much ready to go at the Vera institute, I think it's fair to say that it will be more difficult today to do what we were trying to do at the Vera Institute in 1971. This interpretation is based on my belief that in our country there was less of a moral crusade in 1971 against drugs and against the addicted than there is today.

A second recollection is something that came out of the Drug Abuse Council work. The National League of Cities, under the leadership of Richard Hatcher who was the mayor of Gary, Indiana, passed a resolution that some cities should be able to develop a plan for a heroin maintenance trail. The Drug Abuse Council provided a publication of the 1977 meeting at which I and others discussed the pros and cons of the National League of Cities proposal.

Several opinions were expressed. One government official thought it was politically dead before it started. A clinician voiced concern about competition with the growth of methadone maintenance therapy. The National League of Cities never pursued the matter.

A third experience that I had was at the drug research meeting of the Committee on Problems of Drug Dependence. I met there with a small group of established researchers. We discussed the possibility of a limited heroin maintenance trial in the United States. As I recollect from that meeting, many of them, first and foremost, thought it wasn't feasible. This was before the Swiss trial, so I think the Swiss trial is particularly informative in this regard. Others worried about the Drug Enforcement Administration, which they feared would be so harassing that starting a trial wouldn't be worth the trouble. The investigators had other priorities in their lives than fighting off a regulatory nightmare.

Furthermore, there was also some discussion about how viable a public health outreach heroin maintenance would be, for instance, in terms of AIDS prevention. And lastly, buprenorphine was in development at that time, and some thought this would be the most effective maintenance drug.

So, with those recollections, I will leave you to the next speaker and open discussion of this issue amongst us. I think one of the great things about this conference, particularly for the United States, is it begins to cut away at the fundamental prohibition, which is to discuss these issues openly.

Thank you. First, I really am pleased to be here and congratulate everybody that put this together and those of you who have attended. This sensible and scientifically oriented conference begins to open up discussion for us in North America and the United States about issues that I think are critically important for us to discuss openly.

Let me comment briefly on what I have heard today and also on my experience with the heroin maintenance issue in this country. I think the presentations were excellent this morning-scientifically sound, although it is a difficult clinical trail, cumbersome clinically because of the pharmacological properties of heroin, and not an easy trial to sponsor from a medical point of view. On the other hand, it is clinically relevant to the traditions of medicine, reaching out to a population in need and socially responsible.

I was interested in Dr. Uchtenhagen's comment that the police reported little, if any, trouble from their trial, virtually no complaints from neighbors. The Swiss trial was a discreet and contained project, time limited, carefully planned with a small number of addicts enrolled in the study.

The Swiss investigators had to overcome some objections; public health, medical, political, and enforcement, but nonetheless, they were able to do so. When there was a plebiscite on the project in Switzerland, the public spoke out in strong support of their project.

What was not presented was how heroin maintenance will lead to a general solution of national drug problems or how heroin maintenance will be the cutting edge of drug law reform. I believe Dr. Uchtenhagen's closing comment was that this is not the first step in the legalization of heroin, and I would say not in Switzerland and not in the United States either.

It's also clear how culturally imbedded these projects are, and in many ways need to be. This is not a project that can be exported whole. It appears that while national policies may vary, it's interesting to me that the public still favors abstinence as a treatment goal. But where these projects are occurring, that preference of the public has not been translated into a zero tolerance policy.

In both proposed and already conducted trials, I note that functional improvements as well as drug use measures are important, as they should be, to a positive outcome. Also all the projects, one way or another, were planned in conjunction with the government. I am looking to Switzerland, the Dutch and, to some extent, Australia as examples in this regard and contrast them with our experience in the United States where the government would be a less likely partner in the planning process.

I believe that this morning's presentations and discussion, were very positive in terms of moving forward in a scientific and clinical understanding of heroin maintenance issue. My own view is shaped in part by my experience with these three national projects. I had a chance to review and comment on each one of them and had a chance to visit the clinics in Switzerland at the invitation of the Swiss Federal Office of Public Health with my colleague at Brown University, Dr. Robert Swift, who is a psychiatrist and a psychopharmacologist. We saw first hand what was happening there early in the trial.

In the United States, if I reflect on the history of heroin maintenance here, there was the Vera Institute of Justice project proposed in the early seventies. That project, for which I was offered the medical directorship, was a project that was primarily intended to use heroin maintenance as a time limited transition to methadone maintenance or to the option of detoxification to drug-free treatment.

The project was approved by the City of New York, it was approved by the State of New York, and it was disapproved by the federal government. According to Herbert Sturz, who was the director of the Vera Institute at the time, he believes that the decision was made at the White House, possibly to resolve differences among federal departments at the time.

The reason I believe it was disapproved is, that it was "delivering the wrong message." But I can tell you with the city and the state approval then and the plan pretty much ready to go at the Vera institute, I think it's fair to say that it will be more difficult today to do what we were trying to do at the Vera Institute in 1971. This interpretation is based on my belief that in our country there was less of a moral crusade in 1971 against drugs and against the addicted than there is today.

A second recollection is something that came out of the Drug Abuse Council work. The National League of Cities, under the leadership of Richard Hatcher who was the mayor of Gary, Indiana, passed a resolution that some cities should be able to develop a plan for a heroin maintenance trail. The Drug Abuse Council provided a publication of the 1977 meeting at which I and others discussed the pros and cons of the National League of Cities proposal.

Several opinions were expressed. One government official thought it was politically dead before it started. A clinician voiced concern about competition with the growth of methadone maintenance therapy. The National League of Cities never pursued the matter.

A third experience that I had was at the drug research meeting of the Committee on Problems of Drug Dependence. I met there with a small group of established researchers. We discussed the possibility of a limited heroin maintenance trial in the United States. As I recollect from that meeting, many of them, first and foremost, thought it wasn't feasible. This was before the Swiss trial, so I think the Swiss trial is particularly informative in this regard. Others worried about the Drug Enforcement Administration, which they feared would be so harassing that starting a trial wouldn't be worth the trouble. The investigators had other priorities in their lives than fighting off a regulatory nightmare.

Furthermore, there was also some discussion about how viable a public health outreach heroin maintenance would be, for instance, in terms of AIDS prevention. And lastly, buprenorphine was in development at that time, and some thought this would be the most effective maintenance drug.

So, with those recollections, I will leave you to the next speaker and open discussion of this issue amongst us. I think one of the great things about this conference, particularly for the United States, is it begins to cut away at the fundamental prohibition, which is to discuss these issues openly.

Thank you.