EXTREME PLEASURE'S EXCESSIVE PRICE

Ordinarily, most of us don't consider the extent to which we are chemical
creatures, which is probably as it should be. However, the recent influx of
heroin into Massachusetts is a pointed reminder of our vulnerability to the
addictive power of opiates. A number of unfortunate individuals, some of
them adolescents, have received a crash course in the neurobiology of
dependence, and its consequences aren't pretty.

Over the last four years, heroin has overtaken cocaine as the drug of
choice of those coming into treatment. Purer and cheaper than ever, it
seems less threatening to new users than in earlier heroin epidemics: It
can be snorted or smoked, so the stigma associated with injection and the
risks of needle-transmitted disease are avoided. At first.

Most, perhaps nearly all, heroin inhalers start out assuming they will
never inject. But the sad fact is that many eventually will, as buddies who
use needles persuade them that there's a better rush to be had, or that
their drug dollar goes further when heroin powder is cooked up into an
injectable solution.

What at first seems beyond the pale becomes a necessity as addiction takes
hold, and then HIV, hepatitis, and other needle-transmitted diseases run
rampant. Even those who are smart enough not to inject aren't immune from
getting hooked, as statistics on treatment admissions show. Over 30 percent
of those in Boston's publicly financed programs for heroin abuse primarily
inhale or smoke the drug.

From all accounts, heroin delivers unparalleled pleasure, which is
precisely why we shouldn't use it. We're all possessed of a ''reward
pathway'' deep in the brain, bequeathed us by evolution, which makes us
seek out those things - food, sex, approval, mastery, novelty - which have
contributed to survival.

Heroin is particularly suited to giving us the reward - in spades - but
what gets rewarded is drug-seeking and drug-using behavior, not anything
like what nature originally ''intended.''

So we get drastically spoiled and sidetracked by heroin; nothing else in
life compares with those first hits. But beyond that, heroin changes the
brain so that it's less a matter of getting high than avoiding the misery
of being ''drug sick.'' And with some addictions researchers believe the
changes are nigh irreversible.

If history is any guide, law enforcement efforts to block the supply of
heroin and other drugs will have little impact on availability, which means
that, short of emulating the Big Brother approach of Singapore, addictive
substances will always be with us.

The challenge, therefore, is to deflect potential users - mostly
adolescents and young adults - from experimenting with the cool new drug in
town. But how?

Since teens detest the thought that anything might control them, prevention
in communities and schools must send the message that anyone can be
victimized by opiates. It's your very brain you put at risk, your very
autonomy. In focus groups, teens tell us that this message is best
delivered by peers who have fallen to addiction, or by educators who gain
credibility by acknowledging the realities of adolescent substance use
instead of hiding behind a simplistic ''just say no.''

Parents can help by staying connected with their children, but without
being punitive, and by modeling moderate and responsible drinking if
alcohol is used at home. Media campaigns must be tailored to an
increasingly sophisticated young audience that is seriously unimpressed by
drug war hype. Although any drug can be abused, teenagers know that
substances differ in their risks, so an effective message about heroin
won't necessarily work for marijuana.

Most basic, though, is making sure that youngsters have better things to do
than get high, and have legitimate expectations for the future. Although
even the most privileged adolescent can ''graduate'' from alcohol,
cigarettes, and marijuana to hard drugs such as heroin, the chances of
becoming a confirmed junkie are far greater when life opportunities are
scarce.

This means making substantial investments in high-risk schools and
communities to boost educational achievement, extracurricular activities,
job placement, and ultimately each individual's sense of self-worth and
responsibility. Neighborhood and peer norms condoning high levels of
substance use can change if attractive alternatives exist, and creating
these alternatives will pay off handsomely since it's far less expensive to
educate than imprison, to prevent rather than treat.

Until we are willing to make these investments, cheap, pure heroin, as well
as other drugs (alcohol and nicotine primary among them), will continue to
take their toll, and we'll be left dealing with the detritus of addiction.
In the short term, this means making treatment available on demand, and
reducing the risks of injection-transmitted HIV and hepatitis by expanding
needle exchange in Massachusetts.

But in the long run, to effectively combat our built-in vulnerability to
drugs we must take on the whole prevention challenge: school, community,
and jobs development, increased parental involvement, better substance
abuse education, and more savvy media campaigns. The tide will turn when it
becomes clear that life has a lot more to offer than a cheap high.