CONTAMINATED HEROIN MYSTIFIES AND SCARES BRITAIN

GLASGOW -- They started showing up in hospitals here in the middle of
April, gravely ill heroin addicts with huge, painful skin abcesses,
skyrocketing white-blood-cell counts and dangerously low blood
pressure. Since then, 63 similar cases have been identified, as far
afield as Dublin, Liverpool and Manchester, and 32 people have died.

The outbreak is most likely caused by bacteria in a contaminated batch
of heroin, experts said. Doctors said they did not know whether the
contaminated supply had been exhausted or whether there is more,
perhaps much more, to come.

The outbreak has sent shivers of fear through the communities of
hard-core heroin users in Britain and Ireland linked, city to city, by
a drug-supply chain. The wave of deaths has also presented British,
Irish and American investigators with a stubborn medical mystery as
they try to identify a cause. Two investigators from the Federal
Centers for Disease Control and Prevention in Atlanta flew in to help
recently. But they have not been able to determine what the culprit is
or what batch of heroin is harboring it.

Although heroin is a notoriously high-risk drug whose use carries a
high mortality rate -- Glasgow, with 611,000 residents, had 150
heroin-related deaths in 1999 -- public health officials said they had
never faced anything like this.

"I've been in the business for 13 years and I've never seen any cases
like this before at all," said Dr. Laurence Gruer, a consultant in
public health medicine at the Greater Glasgow Health Board. "My
colleagues in intensive-care units have never seen people like this,
who've been dying so quickly. And the pathologists who perform the
autopsies have never seen anything like this before, where when they
opened up the bodies, the internal organs looked quite clean. It
really does seem like this is a silent killer."

It is no coincidence that 35 of the reported cases, and 17 of the
deaths, have come from Glasgow, where heroin found a serious foothold
20 years ago. Even as Glasgow undergoes something of a cultural and
business renaissance, officials estimate that as many as 12,000 to
15,000 heroin addicts live here, many sleeping on streets, in homeless
shelters or in the public housing complexes that dot the city.

"They live in a different city from the one we live in," said Jonah
Sullivan, project manager for the Gorbals Addiction Service, an
outreach program in Glasgow. "A lot of heroin users live outside of
our experience entirely."

After the first few cases, which were ascribed to overdoses and then
re-examined in light of new evidence, the pattern became clear. All
the victims have been "muscle poppers," addicts who inject heroin
directly into their muscles, usually because their veins have been so
badly damaged from long-term drug abuse -- and more than half have
been women, because female addicts are reportedly more likely to
inject into their muscles than male addicts are.

The illness begins as an infection on the spot where the heroin was
injected, usually in the arm, leg, buttocks or groin. The primary
infection becomes grossly swollen and painful, killing surrounding
tissue and requiring large chunks of affected flesh to be surgically
removed. Unless treated at the initial stage, the infection sends
deadly toxins coursing through the bloodstream, leading rapidly to
heart failure. Of the patients admitted to Glasgow hospitals in the
second stage of the illness, 90 percent have died.

"We found that once they became ill they tended to die within 24 to 48
hours," Dr. Gruer said. "Their hearts failed, even though the ICU
physicians were pumping them full of all the drugs they could think
of. None of them were having an effect."

Health officials have not identified the victims by name or released
more than sketchy details of the cases. But several addicts and
drug-treatment workers interviewed here described watching friends and
clients die from the illness.

Kathleen Rozanski was an early case. Ms. Rozanski, an addict in her
mid-20's, developed an infection that looked like a hard-boiled egg on
her stomach and began to behave as though she were losing her mind,
said Tessa McKay, 24, who was interviewed in the Turning Point Drug
Crisis Center, a 24-hour clinic. "She was acting strange, forgetting
things," Ms. McKay said. "It was as if her memory was gone."

But her friend refused for several days to get help.

"She started to go blue," Ms. McKay said. "And when she got to the
hospital, she was already dead."

In their search to pinpoint a cause, investigators have ruled out
contamination of the citric acid that addicts use to dissolve heroin
and the injection needles. The researchers have ruled out anthrax and
botulism, both suspects at one point.

The most likely explanation so far, Dr. Gruer said, is that the cases
all stem from heroin that has been unknowingly contaminated with a
type of clostridium, a bacterium commonly found in soil and dust that,
in the form of spores, can live in a dormant stage for years.

"In the right situation," Dr. Gruer said, "if they get into the body,
especially into dead tissue, they can be activated and start
multiplying, and cause an infection, which then produces a deadly toxin."

But even if the culprit is identified as clostridium, it remains
unclear what treatment can be developed to eliminate the toxins that
the bacteria throw off.

Although the pace of the illness has slowed, it has proved hard to get
the bad heroin off the streets. Several new cases were identified
early in June. Part of the problem is that by the time most addicts
with the illness reach a hospital, they have exhausted their affected
supply and there are no narcotics left to examine.

"The difficulty is that we don't know how the batch was prepared or
its size, whether it was 1 kilo," about two pounds, "or 100 kilos, or
anything about it," Mr. Sullivan said.

Most of Britain and Ireland's heroin reportedly originates in western
Asia, enters Britain via Dover and travels through Liverpool before
heading farther north, where it reaches the streets through a vast
network of small-time dealers.

It seems highly likely, said Dr. Joe Barry, a specialist in public
health medicine at the Eastern Regional Health Authority in Dublin,
that the heroin was contaminated after it had left its source, perhaps
by dealers here who were trying to increase its bulk with other substances.

"It's hard to know whether we're at the beginning, middle or end of
this," said Dr. Thomas Gilhooly, a general practitioner with a large
number of addicted patients in Glasgow's depressed East End and the
clinical director of the Lanarkshire Drug Service outside the city.

There is one positive development, Dr. Gilhooly said. The deaths have
so terrified some addicts that, unable to quit altogether, they have
at least switched from injecting to smoking heroin, a safer if less
potent method.

But change comes hard to heroin users. "While many of them are very
concerned, they can also be quite fatalistic," said the Turning Point
project manager, George Hunter. "Given that they're injecting
themselves three, four, five times a day, this is just one more risk."

Willie Scott, 28, who has been using heroin on and off for six years
and is one of 12 addicts in the Turning Point residential program,
agreed.

"Every time you take a hit," Mr. Scott said, "you're taking a chance
of killing yourself. We all know that. I've lost best mates. But
heroin is such a gripping drug. It gets such a hold of you that even
seeing your best friend lying dead in a coffin isn't enough to stop
you from injecting."