The First International Conference On Maintenance: Legal/Policy Strategies, Michael O'Shaughnessy

Yes, I come from this at a little different angle. Like as Marty Schechter said, my program treats 5,000 HIV positive people. We give antiretroviral treatments. It's a huge program, financial program. And I was one of the founders of the Injection Drug User Study in Vancouver where we've seen prevalence go from 5 percent to 40 percent in two years. An incredible epidemic.

And so we started to look at alternatives. Because when you see the toll that -- There are three epidemics, drug abuse, hepatitis C and hepatitis, and HIV of taking -- in the users. It's just incredible. Now, but we are grounded in reality. And so I was asked, "Well, what are the obstacles doing a trial?" Well the main obstacle, and I think Pierre Trudeau, who was our Prime Minister through the '60s, '70s and '80s, he said it all. When you're in bed with the elephant, when they twitch you jump.

And what he meant was we're contiguous to the United States, and any policy we want to make that's controversial, the Americans will influence it. Now, the reality is we got dragged in to the debate on needle exchange because we did a paper, we published a paper in Vancouver. So I would say first of all that would be our biggest obstacle, the American political situation and the ability of the American government to influence Canadian politics.

So we would first have to get a Minister who had some courage, and a government that had some courage. A trial could happen in Canada. Because under the Controlled Substances Act, there is a provision for heroin providing through the medical licensing of heroin. It already exists in the law, so we wouldn't require a Parliamentary decision or a vote in Parliament to change the law. We would just need the Minister to say "I give authority for this use." But that would be a big step, because I can tell you there would be -- I don't want to say, you know, I can't say there would be influence, but I suspect it would be a point where influence could be applied in our country.

And right now the opposition in our country is very right wing, it's call the Reform Party, and they would have a field day with a clinical trial. So the obstacle for us or the imperative for us would be to design a trial that would give an answer that would allow the politicians to take comfort. And I don't mean comfort give them the answer they want, but let them know that it was scientifically sound. Because if a government chose to do it, they would be under considerable attack.

However, and I would say Ministers sometimes have courage. And there were two that I'll think about. One is in our system we provide needles in prisons. Not the federal prisons, in the provincial prisons. And 10 years ago I was in our Parliament when the Minister made a snap decision to provide condoms in prisons. Now, that's a big issue for a conservative government. Occasionally it happens. So I would say don't quit, keep the pressure up, because sometimes we can change governments -- uh, change government policy.

Oh, we could change governments too, but sometimes there's not a change, you know. They change faces, but not philosophies.

The other issue for us is that the Minister in Canada has delegated to the provinces the authority on methadone. And you would think the authority also on -- if he's delegated for methadone, he would delegate the authority for heroin prescription. And that would be a problem for some of the provinces, because we're not a homogeneous country. Some provinces are very right wing. The province in which I live now is called the New Democratic Party, it tends to be more of a socially conscious party. And I'm not sure that the country would agree, the various -- the 10 provinces and the two territories would agree unanimously to a trial. So this would be another obstacle, and that would be at the provincial level. And that's critically important, because the provinces fund the health care system. The federal government doesn't. Everybody thinks they do, but they don't. The provinces fund it.

And the other obstacle for us would be in the municipal governments. Now, you would say, well, what the heck does the municipal government have to do with anything? Well, for instance, we just spent the less -- I still spend time, and I have to give a talk next week to the City Council where we have to explain to them that in fact needle exchanges are a good idea. Because the City Council now -- because, as you know, in elections you get a progressive government and then a less progressive government. So right now we're into having a right wing government where they want to cancel needle exchanges. They think because we had a high sero incidence, this is evidenced that the exchange has failed. The fact that they canceled all the drug and alcohol treatment programs and all the social housing, they think that had nothing to do with it.

So the obstacle for us then is that at all levels of government, the federal, the municipal and the provincial.

And the other thing, and I didn't hear this -- the other strange thing in Canada, and you probably think that Canada has a great socialized medical system, but we have user fees. For instance, if you go to a methadone clinic in our country in our province, you have to pay $70 $75 a month. So you know what that means for the inner city user? He's got to commit another break and enter. Because in our study I have 2,000 of them, and you ask them "What does this mean for you?" They say, "Well, it means I need 75 more dollars if I'm going to go into a methadone clinic." So this is just a bizarre obstacle for us. Because if we were to do a heroin trial, I would suspect they would invoke some type of user fee. So we have all the levels of government that we would have to convince.

But I think the number one would be -- and I agree with my colleagues -- the number one imperative for us would be to get protection from the international governments. And I don't mean just the American, but there are other ones as well, there's the UN and others. And that would be a big problem in our current situation. Certainly the US I believe would try to influence whether or not we could do a trial.

AUDIENCE MEMBER: $7 a day?

MICHAEL O'SHAUGHNESSY: Yeah, that's a lot of money. It's interesting in Canada, one of the other obstacles for us is that the College of Physicians and Surgeons in British Columbia has been positioned against the heroin trial by the methadone prescribers. And you know what? I think it's based on -- I think their position is an ideological position, in that they believe that methadone is the answer.

But in our study that we have of a couple thousand current injection drug users, we have what we call the rule of two. Only 50 percent want methadone. Of the 50 percent that wanted methadone, only 50 percent of them actually took the methadone. And 50 percent of them stayed on it. And guess what? In our study, because this is really an inner city study, they still share needles and they still use cocaine. Because in our population, it's quite different in Canada, in that in the west and in Quebec City, Montreal and Ottawa, heroin is a problem, but the drug of choice is cocaine. We have a huge problem with injection cocaine.

However, we say, because some of the Swiss data says, well, maybe cocaine usage dropped. So certainly the academic side said, "Well, maybe we should look at whether heroin could drop cocaine usage." Because it doesn't seem, and certainly in our embedded population of users, it does seem that methadone has dropped cocaine use in our population in Canada.

ANTHONY MARCUS: I'm Anthony Marcus, I'm on that National Institute of Drug Abuse, studying heroin in the 20th Century. And I have questions about what Michael O'Shaughnessy -- about Canada and Australia. One of the big themes today has been sort of good science but bad politics, and the intention that we have, this problem basically to produce good science, and it's just bad politics. Could you tell me something about any possible initiatives in Canada or Australia to get through that thing with public opinion in this kind of direction. Because as far as I can tell, your description of what John Howard is saying is exactly the same thing that a Labor government would also take. And so I don't think we could [UNINTEL] that either candidate would provide something better. And I think the NDB and the Reform Party are under the same kinds of pressures from the mass media, from the police establishment. So you paint a pretty grim picture of the possibility of science succeeding politics. Because regardless of how many good Swiss studies we have, Canada is still politically, geographically contiguous to the United States. And Australia is still politically and economically contiguous. It might be worth remembering that the US had a lot of hand in bringing down the popular [UNINTEL] of the Australian government. So it seems like the only way is going to be some kind of popular education, some kind of initiative to really take people's hearts and minds and force people to look at this. And I'm wondering what kind of initiatives there are that involve certain popular groups, academics, things like that.

MICHAEL O'SHAUGHNESSY: Just a couple of things. A group put together actually for the government, but they distanced themselves on it, it's called an HIV/AIDS and Injection Drug Use National Action Plan, where a group of essentially academics put together a plan. And one of the things the plan said is, "You know, we ought to look at alternative treatments for addictions. That it may involve clinical trials of this or that. But at least we should look at it, because the data are pretty secure that there's no single use." So this got a lot of play, and we were on the national news, it was sent out to school boards. But the fact is it didn't change government policy for one second.

And all I can say is we continue to try. We do lots of press interviews, lots of radio interviews. But I think it's a long term process. Because I think by and large the majority of the citizens distance themselves, in our country anyway, or in my province, from injection drug users. Because although they're not always representative of the poor, they are by and large the poor. Certainly in our study they have less than a complete grade school education, they're often natives, they have no money, the women are usually involved in the sex trade. So there's no empathy with the rest of society.

ANTHONY MARCUS: Is it [UNINTEL], the way we have certain [UNINTEL]?

MICHAEL O'SHAUGHNESSY: No. One of the weaknesses in Canada is that we don't have an advocacy group, certainly in the west, who speaks for injection drug users. And the Minister just gave a million dollars, the federal Minister, to British Columbia. And one of the things they did, the Medical Officer of Health said "We need to have a group of users," and he was going to put the money to that. And I think that's great. Because I think the users need to collect support from the non using population. And we can try as academics, but we need the users to work with us to do that. Or else there's no empathy, no support, and we're never going to move anywhere.

ANTHONY MARCUS: There is a group in Vancouver, Vancouver Area Network for Drug Users in Canada.

MICHAEL O'SHAUGHNESSY: Right.

ANTHONY MARCUS: There's also a group in Toronto -- a --

MICHAEL O'SHAUGHNESSY: Yes. But the group in Vancouver is not a group that is a very big group or a very powerful group. And it doesn't represent all of the people.

ANTHONY MARCUS: More [UNINTEL] in Toronto -- powerful --

MICHAEL O'SHAUGHNESSY: Right. Yeah, right. Sorry. [LAUGHS]

ANTHONY MARCOS: For that.

MICHAEL O'SHAUGHNESSY: Yes.