The First International Conference on Heroin Maintenance: Introductory Presentation, Ethan Nadelmann

Alan, thank you very much and thank all of you for coming here on this beautiful Saturday in New York at such an early, early time of day.  I direct the Lindesmith Center, which is a drug policy think tank or institution, based in New York with an office in San Francisco and an extensive grants program in Central and Eastern Europe established in 1994.

And our mandate is two fold.  The first is to broaden and better inform the dialogue about drugs, drug users and drug policy both in the United States and around the world through the dissemination of information, the convening of conferences, the publication of materials and what have you.  In some respects, our niche has oftentimes been that of pushing in those areas where the U.S. government and other city and state governments are most reluctant to open up debates and discussions. 

The second brief of the Lindesmith Center is to advance harm reduction perspectives on dealing with drugs, drug users, drug treatment and drug policy.  Harm reduction, defined both in the narrow sense of applying to those efforts that seek to reduce the negative consequences of drug use, even among those people who cannot or will not stop using drugs immediately.  Harm reduction in the broader sense of focusing on drug policy objectives as two fold; seeking to reduce both the negative consequences of drug use as well as the negative consequences of our drug prohibitionist policies.

And finally, harm reduction in the ethical sense.  That we have a preference, almost a knee-jerk preference, that when it comes to dealing with drug addiction and with drug treatment and the interventions that are taken, that there should always be a preference for non-coercive approaches that seek to address the real human needs of people who are having problems handling drugs in their lives.

Now, this conference, and here I want to first thank -- I just need to thank a few people at the start.  First is the person who really did most of the work of putting this together, and that is [HOLLY CATANIA?], my associate at the Lindesmith Center and if she could just stand up.  [APPLAUSE] Where is Holly, do I see Holly?  Yes.  And secondly, [EARNEST DRUCKER?] of Montefiore Hospital who played a key role in helping to initiate the thinking and the work for us.  [APPLAUSE]

But also the other sponsors.  I want to, you know, Beth Israel Medical Center, [BOB NEWMAN?], which Bob Newman headed before and still heads in some other respects.  [ALLEN ROSENFIELD?] of the Columbia School of Public Health.  [SPIKE FORMAN?] at Montefiore, [JERRY BARRENDES?], New York Academy and [MIKE MERSEN?] at the Yale School of Public Health.  All had the willingness and the courage to associate themselves with sponsoring a conference on what everybody knows and understands, at least in the United States, remains a very controversial subject.  So, I'm grateful to all of them for being willing to join in this effort.

Now, there's a basic question here which is that when one is dealing with the problems that heroin addicts run into in their lives, can a program of prescribing pharmaceutical heroin to junkies, to heroin addicts, prove successful not only in reducing illegal heroin use but also other illegal drug use, and also prove successful in reducing the death and the disease and the crime and the suffering associated with both illegal heroin use and our efforts to control heroin availability, and at the same time, help people to stabilize their lives, to lead a better life, in the positive sense?  Not necessarily in the sense of being entirely drug free but in the sense of leading a better quality of life. 

Now, I'm a tremendous admirer of what the Swiss have done.  They really set out, they started to talk about this, and they did it.  They set up a trial and they've come up with a huge amount of fascinating information in this area.  So I'm delighted that they will have the opportunity, really, to keynote this conference.

The Australians have discussed this in depth.  Gabriele Bammer has done remarkable work over the last five or six years in analyzing almost every aspect of conducting heroin trials.  In the Netherlands, Wim Van den Brink has led a research effort that may culminate soon in the initiation of heroin trials here.  Now in England and in other countries, there are studies to look at this.  And we expect that in Germany and in other countries as well, trials will begin in the coming years.  

The tragedy, of course, has been that in the United States, there has been no discussion, virtually none.  The leading researchers from Europe and elsewhere are rarely if ever invited to speak at these events.  The National Institute on Drug Abuse, National Institute of Health convenes meetings and seminars and is fearful lest anybody even raise this issue from the floor.

One reason this conference is on a Saturday is so that people in the U.S. government with an intellectual interest in this subject can feel free to come without having to explain to their superiors why they were taking off a day to hear about heroin maintenance trials.

So I want to just finally say there obviously is a legitimate scientific question here and the [UNINTEL] will be very, very much on encouraging the notion that, not just in the U.S., but Canada as well, that in North America there is a possibility to move forward on heroin maintenance trials of various sorts in different cities around the continent.

But there also, of course, is this political dimension, which is what this conference is intended and designed in good part to really open up a debate, open up a dialogue, put this out on the table in the United States, push away the political and intellectual blinders that have kept this from being discussed more openly here, to legitimize the discussion of this subject.

Now, from my own perspective, speaking in some respects as an activist, this effort does go hand in hand in some respects with what's happening in the United Nations this coming Monday, Tuesday and Wednesday, where the U.N. is holding a major global drug summit that will be addressed by President Clinton and 20 other world leaders.

This is an interesting contrast to that event because here is the science, here is, I hope, the calm and rational discussion.  When it comes to the U.N. event, the Lindesmith Center is involved in a different sort of response, and I hope you will all purchase the New York Times on Monday to see what that response is.
I finally need to make just one apology before introducing the speakers, and that apology is that there is no panel here, or deep inclusion on the podium by patients and clients, those people in Switzerland and in England who have been involved as clients, and whose perspective is unfortunately not as present here as it should be.  We made efforts.  It was a little tricky and complicated to arrange for people who are on heroin maintenance to come to the United States.  [LAUGHTER]

It might have been possible one way or another, so I regret that, but there are, I think, people in the audience and I think we'll have a video so at least that perspective will not be ignored entirely, and I also have -- will ask the speakers to consider those perspectives in their comments.

Let me begin by introducing Thomas Zeltner, Dr. Thomas Zeltner.  Since 1991, Dr. Zeltner has been the Director of the Swiss Federal Office of Public Health.  He's also a Professor of Medicine at the Medical School of Bern.  He's Chairman of the Governing Council of the International Agency for Research on Cancer, and was Executive President of the WHO Regional Committee for Europe. 

Dr. Zeltner received his MD from the University of Bern Medical School, he attended the University of Bern School of Law, and he owns a nice little vacation house on Cape Cod, so he knows America quite well.  I met him just once in late 1992, I believe it was a day or two before or after a major vote in Bern in the federal government about moving forward and it's quite remarkable to see what has happened since that time.  Dr. Zeltner.  [APPLAUSE]

ETHAN A. NADELMANN, JD, PHD:  Thank you very much, Dr. Zeltner.  Before introducing Ambros Uchtenhagen, I just want to make a brief comment about the broader context of heroin maintenance treatment.  Which is that when it comes to drug treatment, obviously I think many of us share the view that it's always a matter of different strokes for different folks.  No one method works for everybody, and probably no one method works for nobody.

When it comes to maintenance treatment, the perspective of the Lindesmith Center and I think many others here is that methadone maintenance has really proven itself over the years to be the most effective form of treatment for the most number of people in reducing not just illegal heroin use, but the death, disease and crime and suffering associated with illegal heroin use.

But there are a wide variety of options.  Now, I should say that this conference is only part one of a two part series.  There is a second conference, of which I believe many of you are aware, September 25th, that will also be here.  And that will really look at the issue of between oral methadone and injectable heroin. 

It will look at the experience, for example, of injectable methadone in England, where 10 percent of the people on methadone maintenance receive an injectable form.  It will look at the experience of maintenance with codeine with Germany, where methadone was banned for many years until recently.  And the experience, similarly, with buprenorphine in France, where methadone was banned for many years until recently.

Also, the experience with oral morphine trials in a number of countries going on right now, as well as, I think, we'll address the issue of oral amphetamine maintenance being experimented with in the United Kingdom at this time.

So although the notion here is to some extent to advocate, not so much for heroin maintenance as a policy but for trials in North America, understand that this is part of a broader context where the bottom line is trying to do whatever will work best for those people who are engaged in heroin addiction today.

Perhaps the leading person around the world speaking on these issues today is Ambros Uchtenhagen.  Dr. Uchtenhagen is Professor of Psychiatry at the University of Zurich and Director of the Addiction Research Institute at Zurich University.  He is a member of the WHO Expert Panel on Alcoholism and Drug, the Editor in Chief of the journal European Addiction Research, and board member of the European Association on Substance Abuse Research.

Ambros Uchtenhagen is also chairman of the multinational project, Evaluation of Action Against Drug Abuse in Europe, and Chairman of the State Expert Committee on Drugs.  Founder and past President of the Swiss Association of Social Psychiatry.  Put it another way, when I first began to hear about Dr. Uchtenhagen years ago and I asked who is he, people say, well, he's the Pope of drug research in Switzerland.  [LAUGHTER] Dr. Uchtenhagen.  [APPLAUSE]
ETHAN A. NADELMANN, JD, PHD:  So we have 15 minutes for questions and discussion.  Jason [UNINTEL]  Are we going to ask people to speak at the microphones, is that -- I guess that's the plan, so why don't -- actually, it's behind [UNINTEL] [DONALD GROVE?], and then please line up at the microphones and let Donald first and then Jason and then the next.  Donald.

ETHAN A. NADELMANN, JD, PHD:  Okay, Jason and then we'll go to Bob.

ETHAN A. NADELMANN, JD, PHD:  There are only two minutes left, so if there are maybe just a quick question and answer.  And perhaps we will be able to have the second.

ETHAN A. NADELMANN, JD, PHD:  Okay, there'll be more opportunity for discussion both during the commentator panel at two o'clock, when the commentators will initiate an audience discussion, as well as in the three focus sessions later this afternoon.  I want to thank Drs. Uchtenhagen and Zeltner for their presentations.  [APPLAUSE]   And we will reconvene in 15 minutes sharp.

ETHAN A. NADELMANN, JD, PHD:  Thank you, Dr. Bammer.  I'm pleased to introduce our second speaker, Dr. Wim Van den Brink.  Dr. Van den Brink is Professor of Psychiatry and Addiction at the Academic Medical Center of the University of Amsterdam.  He's Director of the Amsterdam Institute for Addiction Research and Scientific Director of the Central Committee on the Treatment of Heroin Addicts in the Netherlands. 

Dr. Van der Brink received his medical training at the Free University of Amsterdam, studied psychiatry at the University of [BRONINGAN?], and received his psychiatric epidemiological training at Columbia University.  In 1993, Dr. Van der Brink founded the Amsterdam Institute for Addiction Research.  Currently he is the Scientific Director of the Dutch Heroin Study.  Dr. Van den Brink.  [APPLAUSE]