HEROIN FOR HEALTH

Cover Story

A New Scientific Study Investigates the Potential Benefits of Giving
Hard-Core Addicts Their Daily Doses

"Heroin saved my life," Darlene Palmer says. "Heroin and cocaine. I
couldn't deal with reality, so I used them to escape it."

Palmer says she started using at age 11, the result of four years of abuse
at the hands of uncles and cousins, and a mother who did nothing to stop
it. For the next 27 years she lived the junkie life until she kicked
10-and-a-half years ago. "I was tired of being a professional junkie," she
says. "I wanted to die. All the things I dreamed of as a child -
friendships, relationships, children - those dreams don't go away when
you're a junkie, but they get thrown aside. I knew I had to either stop or
die."

Now, as an intervention worker with downtown Montreal needle exchange
facility Cactus, she witnesses the familiar spiral so many heroin addicts
go through on their way to the bottom: petty theft, prostitution,
alienation and, in too many cases, death.

Throw in a justice system incapable of stopping either the supply or the
demand and life can be very bleak for the average junkie. And while some
treatments do work for many addicts, thousands more fall between the cracks.

In her position, Palmer has been able to cultivate trust among hard-core
users, by talking to them without condescension and being able to speak the
same language. She's taking that expertise and putting it to use as the
Montreal users' representative for the North American Opiate Medication
Initiative (NAOMI), a scientific study already underway in Vancouver and
coming to Montreal and Toronto soon - most likely in May.

The research will be carried out by scientists at the University of British
Columbia, the Universite de Montreal and the University of Toronto. The
approach is groundbreaking, at least for North America: a select group of
470 addicts (about 157 in each city) will be given free heroin, three times
a day, seven days a week, for a year, under strict clinical supervision, to
be combined with methadone maintenance therapy. Another group will be given
only methadone. After the initial year, there will be a three-month
transition period, after which subjects will be transferred to a methadone
program or another alternative treatment. There aren't any specific
follow-up plans yet, but Palmer says there will be a wide range of options
available. In Europe, some of the subjects of similar studies are still
being prescribed heroin.

Serious Users Only

The project's goal is not abstinence, says NAOMI's Montreal director Dr.
Suzanne Brissette of the St-Luc hospital's drug rehabilitation unit. It's
harm and crime reduction. According to similar studies in Switzerland and
the Netherlands, only a relatively small percentage of users receiving
prescription heroin treatment quit using altogether. Petty crime, however,
was reportedly down drastically. The thinking behind prescription heroin
treatment rests on the assumption that, if not forced to steal or hook for
money, addicts will be able to make the transition to a more stable life.
Those who want to participate have to prove that they've tried to quit at
least twice, but failed.

"This study is not for recreational users," says Brissette. "We don't want
people to change their behaviour in order to get free heroin. The subjects
have to be injectors. They have to prove that they've been dependent for at
least five years. They have to have failed methadone treatment - they are
chronic and treatment-resistant users."

Volunteers have to provide records from hospitals, treatment centres or
from the justice system. "Users usually have a file somewhere," Brissette says.

The participants, all volunteers ("There is a certain attractiveness to the
idea of receiving free heroin," Palmer says), are recruited from needle
exchanges, treatment services, emergency rooms and the like. Each candidate
will be screened to see if they match requirements, and must sign a consent
form. They will then be randomly separated into either the methadone-only
group or the prescription heroin group.

The heroin group will visit the NAOMI clinic three times a day to receive
their prescribed dose. This will vary from user to user, depending on a
number of factors. They inject on-site - no heroin is allowed to leave the
building - and observed for 30 minutes. Members of the methadone group
receive one oral dose a day. Counselling services are available at all
times, and participants may seek to transition to drug-free or detox
programs at any time. The entire project, from recruitment through
transition, runs for 21 months. The entire cost nationally is $8.1-million,
funded by the Canadian Institutes for Health Research, a federal agency.

As for the heroin, it will come from a pharmaceutical company based in
Europe (Brissette wouldn't say which company provides it, or even which
country it comes from). It will be stored on-site, in a safe, secure
location. Strict security measures, Brissette points out, are in place to
prevent theft. And because heroin isn't legal they have had to seek an
exemption to be able to import and use it for a scientific experiment.

Not Everyone a Fan

If the project sounds controversial, objection hasn't manifested itself
into any kind of wide-ranging, organized opposition. Jim Boothroyd, NAOMI's
national Vancouver-based communications manager, says the only people he's
heard of who were "virulently opposed to the project were a few
not-in-my-backyarders" in Vancouver, mostly business types and condo
owners. "And that's because we had to build a new facility in Vancouver."
In Montreal and Toronto, the trials will take place inside existing medical
facilities - although no one would say where exactly.

There have been anti-NAOMI rumblings in the blogosphere, and the White
House drug czar is, naturally, dead set against it. One American drug
policy analyst quoted in the Globe and Mail called NAOMI an "inhumane
medical experiment" that doesn't help addicts stop being addicted. Other
health professionals have criticized it for being dangerous on both medical
and ethical grounds, saying the criteria for eligibility is too broad and
that users may be at risk of hypoxia, a potentially fatal lack of oxygen in
blood and tissue.

And on Sunday, March 20, the Journal de Montreal ran a front-page photo of
a wretched-looking junkie sticking a needle into her arm, with the
headline, "De l'heroine payee avec VOS TAXES! Une piquerie [shooting
gallery] pour aider les junkies" (Palmer wasn't pleased, saying the photo
was an archive picture of a woman she knows, but "hasn't seen around for
ages." And while the woman did shoot heroin, she also shot a lot of
cocaine. She also gets angry at the term "piquerie" being applied to a
strictly supervised and controlled scientific experiment).

Nevertheless, it seems the Montreal project is being generally accepted by
the community and authorities. What has helped, says Palmer, is the
project's nature and its willingness to work hand-in-hand with other
concerned parties. NAOMI's board includes representatives from law
enforcement, the city and medical professionals. "It's a scientifically
controlled study," Palmer says. "That seems to reassure people. It's very
transparent."

Ethical Perspectives

The thorny ethical questions the project raises persist. While ethics
boards at all three institutions have given the project their blessing,
McGill bioethicist Dr. Margaret Somerville points out in an e-mail that
"informed consent might raise issues because you could argue the consent is
not voluntary - the person agrees to the research to get the drug."

That being said (or written), Somerville writes that projects like NAOMI
can cut the ethical mustard "provided all ethical requirements are complied
with, just as for any other research involving human subjects. If you see
drugs as inherently evil (which I don't but some people do), it can't be
justified. If you see addiction as a disease or disorder and you are
looking for effective treatment (which is not necessarily abstinence), it
can be justified."

It's estimated that there are anywhere between 60,000 and 90,000 heroin
addicts in Canada. With the war on drugs clearly failing, many addiction
experts feel that a new approach to addiction treatment is needed. NAOMI is
taking its lead from Vancouver's "Four Pillars" approach of harm reduction,
treatment, prevention and enforcement.

"The point here is to curb use without punishing the drug user," Brissette
says. "Even under the best treatment system, which Canada's is not, you'll
only reach 50 per cent of the population. The other 50 per cent isn't
reached either because they've tried treatment and it doesn't work, or
because they don't want it. Usually these people are the more marginalized,
the sicker, more disorganized and suffer from mental or social illnesses.
These are the ones we need to attract and retain for treatment. But it's
not easy."

To Palmer, who's clearly excited about the project, the point isn't to
treat heroin as inherently evil; it's to free the addict from the dangerous
lifestyle addiction creates. "We want to change the routine of using, to
change its place in the life of the user," she says. "We want users to
practice taking charge of their lives. We don't ask them to stop using, but
to consider the possibility of changing their lives a little."