GRADUATION DAY

Gary Occhipinti is playing tour guide for the day. Leading a group of
international visitors through the streets of Vancouver, he stops to
point out buildings and explains the history behind them like any
other guide. Except the men and women following him aren't
tourists-they're social workers, researchers and nurses from the 17th
International Conference on the Reduction of Drug Related Harm, and
they're touring the Downtown Eastside to see how Vancouver is dealing
with its drug problem.

As the tour progresses, addicts gather in stairwells and doorways in
the early morning sunrise. Two toothless men pass by, one hobbling
and pushing the other in a wheelchair. Police rifle through the
pockets of a man backed against the wall outside Sheway, a health
centre for pregnant addicts. Stops on the tour include the safe
injection site, a drug users drop-in centre, and the corner of
Dunlevy and Powell where Occhipinti says most of Vancouver's missing
women were last seen. Tour members pose for photos in front of
Oppenheimer Park, a site which Occhipinti notes has a long history as
a drug market.

Occhipinti is a walking piece of history. A self-professed poster
child for heroin maintenance, he's the first participant to graduate
from Vancouver's controversial NAOMI trial-the North American Opiate
Medication Initiative-which gives free heroin to addicts who failed
to kick the habit through typical treatment such as methadone or abstinence.

Fifty-year-old Occhipinti doesn't look like your stereotypical heroin
addict. At six-foot-three and 200 pounds he looks thin but has gained
30 pounds since he started the trial. He has dark, deep-set eyes
beneath bushy, downward sloping brows. His skin is pulled tight over
high-set cheekbones and angular features.

Articulate and talkative, Occhipinti is the first of 137 participants
in Canada to make it through the 12-month NAOMI trial, held both here
and in Montreal. He's nearing the end of the "cooling down" period
and has gradually reduced his dose for the last seven months. As the
end of his supply of clean, prescription heroin approaches, questions
about his future and the trial arise. Occhipinti is confident he'll do OK.

"I've gotten my habit shrunk down far enough that even if they close
the doors on me tomorrow I would survive the withdrawal," he says.

After a year of free heroin, NAOMI participants have three months to
scale down their dose and figure out what they're going to do next.
But in order to qualify for the trial, candidates had to prove
conventional treatment didn't work for them. Their post-trial options
are abstinence, methadone or detox programs, the same approaches that
didn't work before.

With the two largest populations of heroin addicts in Canada,
Vancouver and Montreal were the cities chosen for the NAOMI trials.
Vancouver's drug history is well known. It gained additional
prominence in 1997 when Health Canada declared a public health
emergency for the city after health officials discovered one out of
four injection drug users had HIV. Hepatitis C and TB were out of
control. In 1998, overdose deaths in B.C. hit a record high of 461,
most in the Downtown Eastside, according to the Canadian Medical
Association Journal.

Vancouver's NAOMI trial began enrolling people in February 2005 with
the offer of a year's supply of free, prescription heroin in
conjunction with a rigorous clinical trial. NAOMI proponents say
taking addicts off the street and introducing them to the health care
system reduces property crime. The idea is they won't need to steal
to get money for their next fix and that they will have access to
job-skills training, counselling and assistance in finding housing.

The NAOMI project operates on an $8.1-million budget, an amount
researchers say is miniscule compared to the social costs of
addiction. The Canadian Institute of Health Research approved the
project and wrangled a grant from the federal government to pay its
costs. NAOMI researchers say 60,000 to 90,000 addicts inject opiates
in Canada, and each addict costs taxpayers $45,000 per year through
the criminal justice, welfare and health care systems for a yearly
cost estimated at from $2.7 to $4 billion.

The cost in lives also continues, with an estimated 1,000 overdose
deaths in Canada each year. Occhipinti says he knows what overdosing
means. He claims to have been "clinically dead" when he woke up in an
ambulance, colder than he'd ever felt, after paramedics injected him
with Narcan, a drug used to revive addicts. He was surprised he
hadn't overdosed sooner and was grateful that a friend was brave
enough to call 911. He says a lot of addicts don't call for help
because they're afraid of problems with police.

Before NAOMI, Occhipinti got money any way he could. "It's almost
impossible, unless you're very wealthy, to support your habit without
stealing and dealing," he says. He sold heroin and prescription
morphine and stole when necessary.

"I wasn't a very good thief because I'm too noticeable," he says.
"I'm six-foot-three. It's kind of hard to slide through places and
not be noticed."

How he's made his money during his time on NAOMI is unclear. He won't
say what his current source of income is, but is looking for work in
sales management now that he has more free time.

Born in Kitimat to Italian immigrants, Occhipinti moved to the U.S.
with his parents when he was a toddler. He started using drugs-mostly
pot, LSD and mushrooms-at age 14 while living in San Francisco. "It
was the '60s, it was really exciting," he remembers, noting he never
saw his own parents indulge in alcohol or drugs. "There was a
revolution attached to it... there was a sense that the world was
going to change for the better and people that took drugs in those
days were not taking them to escape, but to expand."

When he was 16, a friend introduced him to heroin. The drug made him
feel complete.

"[He] turned me on to something that his brothers were all addicted
to, his older brothers were all heroin addicts. We thought we would
try it and, no big deal, use it occasionally," he says. "We both
liked it. The missing piece is in place and you feel a sense of ease
and comfort. I'm not talking about being loaded and falling over, I'm
talking about a sense of being in place that isn't possessed before
you discover opiates. The problem is they're really addictive and
very few of us escape that addiction, like myself."

Occhipinti joined the U.S. air force after high school but when drug
testing became mandatory, he had to choose between honourable
discharge or drug testing and a probable jail sentence. Occhipinti
took the discharge. In 1979 he was caught breaking into a pharmacy to
steal morphine. He was sent to San Quentin for less than a month
during processing and relocated to another prison for 16 months. In
1983 he got clean and started college two years later, and in 1988 he
graduated and went to law school.

In 1991 he started "chipping," using drugs here and there after a
doctor prescribed him painkillers for a back injury. He graduated
later that year but a run-in with Nevada police ruined his hopes of
becoming a lawyer. Police found seven ounces of marijuana and took
Occhipinti to jail where forced testing showed traces of cocaine and
heroin in his bloodstream. He was convicted of a felony and spent 22
months in an Arizona prison.

Occhipinti is divorced with an 18-year old son who lives with his
mother in Denver, Colorado. Neither his former partner nor his son
knows about his role in NAOMI. "My son doesn't need to know. He knows
that his dad has struggled with addiction," Occhipinti says.

Statistics on addiction recovery are hard to pin down. Dr. David
Marsh, the clinical lead for the Vancouver trial, says putting a
number to the opiate addicts who get clean is impossible. He says it
depends on the extent of their addiction, the type of heroin they
use, what it's cut with and the treatment addicts choose.

Some try methadone-an opiate derivative that blocks the craving for
heroin and helps ward off the effects of withdrawal. It's as
addictive as heroin, but a single dose lasts 24 hours whereas heroin
usually requires three injections per day to avoid withdrawal
sickness. Many users who transfer from heroin to methadone struggle
with the powerful new addiction and withdrawal symptoms such as upset
stomach, constant diarrhea, and muscle cramping, also known as "worms
in the legs."

But methadone can be hard to get and harder to stay on. Despite a
tenfold increase in availability over the past 10 years, demand for
methadone outstrips supply, says Marsh. Spaces in methadone programs
are limited by the number of well-trained doctors who are licensed to
prescribe methadone and feel comfortable treating addiction. Only 15
to 20 per cent of opiate addicts in Canada are on methadone and of
those who get into a program, studies show, one-third drop out in the
first year and another third drop out the following year.

Occhipinti is one of the dropouts. He tried methadone a few times but
it didn't work. "For some people it's a great substitute," he says.
"For me all it did was it guaranteed that I wouldn't wake up 'sick,'
as we call it in withdrawal. But it doesn't give you any of the
euphoria or the sense of well-being that heroin does."

The NAOMI trial's "harm reduction" approach is part of Vancouver's
Four Pillars drug strategy-harm reduction, prevention, treatment and
law enforcement. It's a European model championed by former mayor
Philip Owen and adopted by his successor Larry Campbell and his
COPE-dominated council. NAOMI researchers cite European studies that
indicate improved health, a drop in illicit drug use, lower crime,
and increased employment for addicts treated with heroin.

The NAOMI trial had 108 participants in Vancouver as of May 10.
Forty-five per cent receive heroin, another 45 per cent methadone and
10 per cent receive an opiate called Dilaudid, a possible third
option for treating heroin addiction. Recruitment is ongoing and
researchers hope to meet their target of 250 participants between the
Montreal and Vancouver clinics by early 2007.

Not everyone can join. Potential candidates must be at least 25 years
old with five years of drug use documented through their medical
records or attendance in detox programs. Using those records, they
must also prove they tried to kick heroin twice and failed. Anyone
facing criminal charges is ineligible, because researchers don't want
participants hauled off to jail in the middle of the research trial.

Participants must live close to the trial's clinic at Abbott and
Hastings, so Occhipinti moved from Mount Pleasant into an SRO hotel
in the Downtown Eastside to qualify. "To begin with I had to live in
the Downtown Eastside area and it was a horrible experience: bedbugs,
cockroaches, murders, stabbings, overdoses, poverty, despair, I mean,
you talk about neglect, police brutality," Occhipinti says. "You live
there every day for a while, and I thought, I've been to prison, San
Quentin, I've done all that, but living down in one of those skid row
hotels..."

Participants attend the clinic three times a day. A nurse gives out
the drugs in clean, pre-filled needles. Participants shoot up under
supervision at the clinic and stay for half an hour so their health
can be monitored. The nurse keeps track of the heroin closely from
behind a glass booth. Each syringe is labelled with a barcode that's
scanned going out and scanned when it's returned empty. Participants
can't leave the building until they return the needle. Security is
tight and the place is rigged with surveillance cameras.

The results of the NAOMI trial won't be available until 2008.
Speaking at the international conference on reducing drug-related
harm, Marsh reminded conference-goers and journalists that
researchers haven't finished the study. He says results might
indicate the need for more and improved methadone programs, which
would also be cheaper than prescribing heroin, but the data is still
being collected on which treatment worked best with the trial's participants.

And as some of these addicts, including Occhipinti, approach the end
of the trial, the ethics of the program have come under scrutiny. The
key question: will the addicts, whose lives may or may not have been
helped by a year's supply of prescription heroin, be allowed
continued access to the drug once the trial is over?

Marsh told the conference he's discussed the possibility of
continuing the program with "various levels of government" but
because of mixed response he can't promise trial participants
anything other than the original deal-one year of heroin and treatment.

Marsh pointed out that in most clinical trials, if the treatment is
working, it's standard procedure to continue with the drug. But
because heroin is illegal, he would be breaking the law if he
continued to give out the drug, even if participants benefited from
the treatment.

Bryan Alleyne, a worker at Vancouver's safe injection site and former
president of VANDU, an advocacy group for drug users, originally
thought the NAOMI project would get addicts out of crime and
prostitution. But he has since changed his mind. "Now that we're
coming to the end of the project, I really don't know what's going to
happen," he says. "If people are going to revert back to crime,
because they do have to feed their habit- their habits have become
enormous since this here NAOMI project."

Alleyne says trial participants need help with job training or
schooling to become productive members of society. He wants to see
the program continue and says addicts will end up back where they
started once the research is over. "If you cut people right off,
people have to survive, they have to feed their habit. Because if
you've been in this program for a year, you got more than a monkey on
your back, you got King Kong on your back because they've been
getting the best of dope."

The Dutch government conducted a similar trial to NAOMI in Holland.
According to its results, 81 to 87 per cent of addicts returned to
dysfunctional lifestyles after their free heroin was cut off.

NAOMI spokeswoman Julie Schneiderman notes that the trial is a
research study, not a treatment program, and while the researchers
are open to the idea of continuing heroin as treatment, they don't
have the money to pay for it or the legal permission to do so. In
2005 Health Canada issued an exemption under section 56 of the
Controlled Drugs and Substances Act that allowed the trial to use
heroin for research purposes only. Prescribing heroin beyond the
original 15 months would be breaking the law.

Schneiderman says government policy makers will decide what to do
after the trial. She hopes they base decisions on evidence, not
emotion or morality.

Timothy Christie, a health care ethicist with the B.C. Centre for
Excellence in HIV/AIDS, says the original point of the study was to
see if heroin prescription helped chronic addicts. Christie says
addicts could be healthier and kept off the streets if the federal
government changed the drug laws. "That's part of the reason we're
doing science is to give evidence to the government to change
regulations," he says.

Extending the prescription heroin program would require approval from
two divisions of Health Canada: the Office of Controlled Substances,
which deals with illicit drugs, and the Therapeutic Products
Directorate, which regulates pharmaceutical drugs. But federal Health
Minister Tony Clement ultimately holds power over any exemption to
the control of heroin.

Robin Walsh, spokesman for the minister, says Clement inherited the
trial from the previous Liberal government but will honour the
agreement. He says Clement wants to focus on prevention and treatment
for drug addiction but couldn't offer any examples on what those
might be. He says it would be inappropriate to speculate on extending
heroin treatment until the final results are released. "We'll be
watching carefully on the outcomes of the project," he says.

At 7:40 p.m. in early May, NAOMI participants shuffle out of the
clinic on to Abbott Street after their evening injection. Two women
stop to talk about their experience so far. Both think the program is
great, one says she no longer has to sell her body and can sleep at
night. The other has gained 40 pounds. Occhipinti steps out onto the
sidewalk. Wearing a white dress shirt and dark sunglasses, he looks
as if he just left a business meeting rather than a heroin clinic.
Walking quickly down Hastings, he says he wants drugs decriminalized.

"It's like Sam Sullivan said- you know what, this isn't about fixing
a problem that's a short term problem with an instant solution. This
is something that you have to learn to live with. I thought he was
very eloquent when he said the disabled as a group- realized they
didn't want doctors controlling their lives. Assistance? Absolutely.
Guidance? Sure, when it's needed. But control never. That's my stance
on prohibition."

He's glad he joined the trial but fearful about facing the end.
"Nothing like this has ever happened to anybody, this is a brand new
thing for a Canadian."

Schneiderman says people coming off NAOMI heroin will get the best
treatment available. But Occhipinti says he already knows methadone
isn't an option for him. "The definition of insanity is repeating the
same action over and over again and expecting different results," he
says. "I refuse to do that. In other words, it never worked before
over a 20-year period of sporadic attempts where one time I was on
for a year and I was suicidal the whole time, slept 20 hours a day
and never felt worse in my life."

Based on the Dutch research, there's a four out of five chance
Occhipinti will end up back where he started before the trial. He
says he has no choice but to face withdrawal. "I could continue to
purchase street heroin but I don't want to go back to that life
cycle. That was the whole purpose of the experiment to see if you
could escape. For myself, I'm part of that big cohort of people who
would like to be clean eventually, but making it illegal does not
help me get clean."

Occhipinti says freedom was his biggest motivation for trying to
quit. "Nobody wants to be tied to a substance or a problem. There's a
part of most human spirits that wants freedom. [For] some of us it's
huge, some of us it's tiny but I believe it's a part of almost everyone."