EVIDENCE AGAINST THE TRIAL

Prescribing heroin looks like a costly road to take in the fight against
drugs before the use of methadone has been properly evaluated. SIMON MANN
reports from London.

"DRUGS capital" is a label readily applied to many big European cities and
while Liverpool doesn't necessarily fit that bill, the city that gave the
world The Beatles and one of the most successful sports teams in history, is
said to be awash with heroin.

It's not surprising then that 2,500 Liverpudlians are on methadone treatment
programs or 5,000 people are on methadone in the Mersey twins, Liverpool and
Everton.

What is surprising, however, is that in a country which has allowed GPs to
prescribe heroin free to drug addicts for more than 70 years, only 30 or so
patients in the city now receive their daily "fix" from their local doctor.
In fact, nationally, there are fewer than 350 addicts taking GP-prescribed
heroin - about 2 per cent of all opiates prescribed for treating drug
dependency in Britain.

Campaigners against free heroin trials say the small number of Britons
receiving prescription heroin, or diamorphine as it is called, is proof that
heroin is not the addicts' "drug of choice" after all. And they add that
searching for new ways to fight an epidemic of drug abuse should not, by
definition, dismiss traditional treatments such as methadone.

"I think people are latching on to the arguments without a lot of evidence,"
said Dr Sue Ruben, the clinical director of Hope House, a big drug
dependency unit in Liverpool with more than 1,000 clients. "While it may
well be that heroin prescribing will help a small number of people, it won't
do anything to contain a heroin epidemic. Why would it?

"People say that you've got to give addicts heroin because they don't come
for methadone. [But] that's just not the case. The case is that everyone
running methadone programs in this country have got far more people wanting
to go on them than they can deal with.

"The other argument people in the UK are trying to make is that heroin
should just be a legalised drug. In other words make it legal, like alcohol.
But that wouldn't do anything. For a start, would that mean heroin was legal
for 10- and 12-year-olds?

"And if heroin just became legal for adults, there'd be a lot more pressure
on people, who have suddenly lost their source of income, to push it on to
children."

The arguments underpin Prime Minister John Howard's reservations about free
heroin, although the so-called Merseyside trial, to which he has pointed,
failed to provide any conclusive evidence either way.

The trial, conducted several years ago, was small, unofficial and not
extensively analysed or logged, say drug workers.

And the need for extensive research to assess properly the pros and cons of
heroin v methadone is further illustrated by the fact that Britain does not
have a national drugs policy or clear rules about who should be treated, how
they should be treated and just what is a "legal dose" for doctors to
prescribe.

Despite its shortcomings, the Merseyside trial, which was spearheaded by
psychiatrist Dr John Marks, did conclude that prescribing free heroin to
addicts short-circuited crime and, because the heroin was pure, improved
addicts' health. It largely eliminated risks of AIDS and other disease
transmission, too.

Dr Marks, who now lives in New Zealand, also managed to garner favourable
media coverage for the trial despite the scepticism of some local health
professionals. He told US television network CBS: "It doesn't get [addicts]
off drugs. It doesn't prolong their addiction either. But it stops them
offending, it keeps them healthy and it keeps them alive."

A former drug information officer for the local health authory, Alan Perry,
says that's because what's been causing the damage has been "the bread dust,
coffee, crushed bleach crystals" and so forth that's been cut into the
powder. "If you inject cement into your veins you don't have to be a medical
expert to work it out, that's going to cause harm," he says.

The Merseyside trial also pioneered heroin "reefers" in an attempt to
dissuade injecting. Patients could hand over their cigarettes to one
particular pharmacist who would inject diamorphine into the tobacco. The
trial ended, however, inconclusively.

One difficulty, says the director of the Scottish Drugs Forum, Glasgow-based
Dave Liddell, is that such trials are carried out in isolation and can
become a "magnet" for users, elevating community anxiety.

"It makes it very difficult for one area to go it alone with a different
approach," he said. "I think the likelihood is that the UK will wait on
developments in Switzerland and Holland. The Swiss are getting some good
results, and certainly some good press, but one of the problems for the
medical profession is that it has already put so much effort into getting
doctors and the system onside with methadone."

As a policy advisory group, the Forum favours heroin trials. As for the
Liverpool experience, however, it had been difficult to get an objective
assessment, Liddell said.

Dr Ruben is less ambivalent, particularly about claims that the trial helped
remove dealers from the streets. "There was very little availability in
Widnes [focus of the trial], which is a small town 15 miles [25 kilometres]
or so away that nobody goes to. It's hardly relevant to the debate because
all the addicts scored in Manchester and Liverpool, anyway. So this idea
that they got rid of heroin dealers was erroneous because if you were a
dealer with any sense you wouldn't be trying to sell stuff in a tiny, shitty
little place that nobody goes to."

Dr Marks, on the other hand, believed that the diamorphine treatment removed
?5,000 ($12,000) of black market business from the streets of Widnes every
week.

Other statistics were bandied about in the Merseyside debate. Dr Marks said
criminal activity among people on the program fell from 6.88 crimes a person
in the 18 months before the start of the trial to 0.44 crimes in the
following 18 months.

A more recent trial in a large West London clinic, where 58 patients were
prescribed free heroin throughout much of 1995 and 1996, went some way
further to demonstrating a link between free heroin and falling crime rates.

The patients were long-term drug users who had failed methadone programs and
who were either unable or unwilling to give up injecting. In the trial,
conducted by a research offshoot of London's Imperial College School of
Medicine, about 60 per cent of those participating chose heroin and the rest
injectable methadone.

The conclusions were positive. "Among those in treatment at three months
there were significant reductions in illicit drug use, illicit
drug-injecting risk behaviour and criminal activity, and considerable
improvements in social function, health status and psychological
adjustment."

The bottom line, say the study authors, was considerable benefit for both
patients and the community. "Prescribing injectable opiates to long-term
injecting drug users is a feasible treatment option."

There is no doubt, however, that the hopes of most British drug reformers
are pinned fairly on the Swiss trials, now in their fifth year, which have
been praised by law enforcement agencies and health officials.

The key findings so far, that shine like beacons in an increasingly gloomy
landscape, include a dramatic fall in crime rates (two-thirds of
participants were involved in some criminal activity at the outset of the
program but now just 3 per cent are) and falls in the incidence of AIDS,
hepatitis and other blood disorders. Numbers of addict deaths have been cut
in half.

The results have inspired universally. As well as Australia, Denmark,
Luxembourg and Holland are apparently weighing up similar treatment options.

Not everybody, however, is convinced that the Swiss success can necessarily
be repeated elsewhere. Some, like London's National Addiction Centre
lecturer Michael Farrell and Wayne Hall, of the Sydney-based National Drug
and Alcohol Research Centre, see shortcomings in the research.

For a start the heroin trial supplemented already well-developed drug
treatments in a wealthy country with a comprehensive health-care system.
There are already 15,000 Swiss addicts on methadone programs and the heroin
trials represented an expensive option for a minority of severely dependent
misusers, Farrell and Hall wrote in the British Medical Journal.

"Given this limited role, the controversy surrounding heroin prescription in
Switzerland and elsewhere has been out of all proportion to its likely role
as a treatment option ..." they said.

"The most important [question remaining] is what is the comparative
usefulness and cost effectiveness of injectable heroin and oral methadone
maintenance?"

Dr Ruben said: "There may well be a place for heroin prescribing. But from
my perspective, there is no single panacea for the problem of drug abuse.
There is no one thing that is likely to contain and control what is a
multi-faceted problem. And methadone programs are not designed to contain
the epidemic in that sense.

"With the best will in the world there just isn't the money and if you
expand the heroin programs you'll have even less money because (using the
Swiss example) it costs approximately 17 times more to treat people with
heroin rather than methadone ... And it doesn't seem to me that methadone
programs are really such a dismal failure."