FREE JUNK FOR JUNKIES

A fix or folly?: Canada plans to follow the lead of other countries and
start giving free heroin to the most desperate addicts. While the
experiment seems outrageous to some, it actually revives a very old medical
practice that met its demise early last century when law enforcement
wrestled the issue of drugs away from doctors

AMSTERDAM - "I have a little bit more money now and it's fun to buy a pair
of shoes or buy a sweater or a book. I love reading. Very soon I'm going to
get a computer."

Marion claps her hands and bounces in her seat, then catches herself and
smiles.

"For other people, these are little things. Normal, daily things. But for
me, it's heaven."

Marion, 44, has been a heroin addict for more than 20 years, a fact that
once dominated every waking moment of her existence. "You get up. You're
sick. What do I have to do to get some money? You start to steal. You sell
it. You buy your stuff." When the drugs are gone, the cycle starts all over
again.

Marion has slept on the streets. She has been raped and robbed, arrested
and jailed. Her body has been emaciated, her veins so ravaged she had to
shoot heroin into her neck and groin. But that is the past. Now she is
almost giddy with optimism.

When she gets her computer, she says, she is going to volunteer for an
addicts' newsletter and use that experience to go after a paid job. She has
an apartment. She is growing close to family members who had long ago
pulled away.

Her health has improved so dramatically she says, "I'm overweight. Well, I
feel overweight because for years I was so thin."

Marion doesn't owe her new life to some miraculous cure. The "cures" have
always failed her. She quit heroin cold turkey many times, she says. Twice
she went into a residential treatment clinic where she received intensive
support for a total of three years. "It didn't help. I kept coming back."

What finally turned everything around for Marion is heroin -- free heroin.

Marion is a patient at the MSU, a little medical clinic in Amsterdam. Twice
a day at the clinic, nurses hand Marion a dose of methadone -- an
artificial opiate chemically related to heroin that has been a standard
method of treating heroin addiction for decades. But Marion also gets a
dose of pharmaceutical quality diacetylmorphine, better known as heroin.
She takes the drugs in the clinic, waits a few minutes, waves and walks out
the door.

Like most addicts, Marion has developed an extreme tolerance for heroin
that makes it almost impossible for her to get high, but she still has to
take the drug to quell cravings and stave off the flu-like symptoms of
withdrawal.

"Now I have my two portions. Then for the rest of the day, I'm not sick
anymore. I don't have to worry about money or stealing. I can do normal
things."

Free junk for junkies: To most, it's a bizarre idea. Heroin is a curse, a
blight. Why would anyone give its victims the very drug that is destroying
them?

But the positive effects the program has had on Marion are unmistakable,
and even her family has decided it isn't such a bizarre idea.

Many others have also been convinced.

In 2002, a committee of Canada's House of Commons recommended a trial
project in this country similar to one in Holland. A team of scientists is
preparing to do just that.

If the trial is approved by the federal government -- final sign-off is
expected soon -- the North American Opiate Medications Initiative will see
pharmaceutical heroin prescribed to 210 addicts in Toronto, Montreal and
Vancouver.

The project is expected to begin this fall.

Radical as this might seem, Canada would only be following an international
trend.

Conservative Switzerland set up the first modern experiment with heroin
prescription in the mid-1990s, producing results so promising the Swiss
expanded the program and made it a permanent facet of health care. Holland
followed with a more rigorous study that ended in 2001 -- again producing
positive outcomes and government approval to continue the research.
Germany, Spain, Italy and Australia have planned or launched their own
projects. The United Kingdom is working on a scheme to expand the
prescription of heroin by individual doctors, even general practitioners.

Whether courageous or outrageous, the idea of prescribing illicit drugs to
addicts has spread with astonishing speed, leading the media and the public
to assume its a revolutionary new idea. It's not.

The continuing prescription of drugs such as heroin to addicts -- or
"maintenance" as the practice is often called -- is actually a very old
medical technique that was dropped in North America when drugs were
criminalized early in the 20th century. The story of how this medical
technique met its demise is the story of how law enforcement snatched the
issue of drugs away from medicine, turning what had been a health issue
into a crime problem. It's the story of how the cops beat the doctors.

For decades, it seemed the story ended there. But the explosive return of
heroin prescription -- along with the spread of "harm reduction" measures
such as needle exchange and safe injection sites -- suggests that medicine
is rapidly taking back control of drug policy.

The doctors would like to deal with addiction as a matter of science and
medicine. But others feel it is also a moral issue.

Illicit drugs are inherently evil, so giving them to addicts is wrong.
What's more, drug possession is a crime, and addicts are criminals who got
into their sorry state by breaking the law. The only help they should be
given is to quit the junk and stop breaking the law. Anything else would be
coddling the guilty.

Here in 2004, it's easy to think that moral condemnation of addicts is
old-fashioned while a non-judgmental attitude is modern. It's also easy to
assume that heroin maintenance is a bold new idea, unlike the old, rigid
insistence on abstinence. But history confounds easy assumptions.

In the 19th century, all drugs were legal and readily available. Drug
addiction was not uncommon, though it was rarely the result of the
recreational use of drugs. Rather it was usually caused by the excessive
use of opium and morphine (and later heroin) in medical care.
Self-prescribing doctors often became hooked. So did soldiers. After the
Civil War, Americans called addiction "the army disease."

Just as the origins of addiction were different, so were the consequences.
Because drugs were legal, they were cheap. An addict didn't have to
bankrupt himself or become a crook to maintain a habit, and so addiction
rarely led to a life in ghettoes and gutters.

And addiction itself was generally not considered shameful. What mattered
was how the addict behaved. The addict who revelled in selfish,
destructive, pleasure-seeking excess was contemptible. But the addict who
worked hard and did all that was expected of a good bourgeois citizen was
just as respectable as any other person.

Much research into breaking addiction was done, and many doctors struggled
to get their patients off drugs. But doctors also knew a regular, low-level
dose of morphine or heroin could keep away the sickness of withdrawal with
little or no impairment of the patient's ability to lead a productive life.
When quitting proved too demanding, doctors gave their patients maintenance
doses.

Examples of successful Victorian junkies abound, but none rivals William
Stewart Halsted. Doctor, co-founder of the Johns Hopkins Hospital, and
creator of so many modern surgical techniques that he is known today as the
"father of American surgery," Halsted was the very model of an active citizen.

He was also a lifelong drug addict. First he was hooked on cocaine but he
replaced that with daily morphine injections -- a regimen that had so
little effect on the surgeon that his addiction remained known only to a
very few friends until decades after he died in 1922.

Halsted's death came at the end of an era in medicine. From the beginning
of the 20th century until the 1920s, social reformers in many countries
scored a series of victories in their drive to criminally prohibit alcohol,
opium, morphine, heroin, prostitution, pornography, gambling, lewd theatre
performances and dancehalls.

The anti-vice crusade was very much a moral reform movement and along with
changes in the law it sought changes in attitude. Alcohol wasn't seen as
just risky to use. It was evil, and anyone who used it was immoral. The
same was true of other drugs, although alcohol remained the focus of
reformers' contempt.

At first, doctors took little notice of the new moralism, assuming that no
matter what the legal status of drugs their freedom to practise as they saw
fit would be untouched; some physicians were even leaders in the
prohibition movement.

Eventually, though, reformers and the criminal prohibition they enacted
succeeded in changing how drugs were seen. Drugs were no longer a health
issue, but a criminal matter. Law enforcement officials became key figures
in drug policy, and police drew a bright line between the legal and
illegal. Drugs were simply contraband, criminal, evil. The context of a
drug's use was irrelevant.

By 1920, as historian David Musto wrote in The American Disease, "advocacy
of maintenance was repressed as sternly as socialism" in the U.S. Doctors
and pharmacists were arrested. Clinics doing the same work the Swiss and
Dutch would experiment with 70 years later were raided and shut down. A
total ban on heroin in medicine followed.

Desperate addicts looked elsewhere for drugs, and a criminal black market
in narcotics blossomed.

Unlike American physicians, British doctors were centrally licensed and
represented by a single, powerful professional organization -- the British
Medical Association -- empowered to discipline members for bad practice.

When drugs were permanently criminalized in 1920 -- a result of a clause in
the Treaty of Versailles, not any domestic problem with drugs -- British
doctors insisted that Britain not use the U.S. model. A leading physician
warned a Home Office committee that the "chief danger" of the American law
"was that attention was apt to be concentrated on the drug itself rather
than upon the patient -- upon the legal aspect rather than upon the medical
aspect."

The doctors got their way. A 1924 report of the Home Office endorsed what
was to become known as the "British system." Where a physician had made
"every effort" to get the patient off drugs but had found the treatment
failed and the patient was incapable of "leading a useful and fairly normal
life," the physician could prescribe a regular, stable dose of the drug.
For the next 45 years, maintenance remained an option open to all British
physicians.

HOW THE MOUNTIES OUTMUSCLED THE DOCTORS

Canada also faced the maintenance question when it, too, criminalized
drugs. Canada chose to follow the American model -- for reasons that had
little to do with principles or evidence.

"In 1920," wrote the authors of Panic and Indifference, a history of
Canada's drug laws, "the Canadian Medical Association was struggling to
recover from the near-bankruptcy it experienced during the war years." And
unlike the British Medical Association, the CMA didn't have the power to
monitor and discipline wayward members, who belonged to the new, fragile,
disorganized provincial associations.

Into this power vacuum stepped the RCMP.

The Mounties had been formed to bring order to the wild North West, which
had been accomplished by the First World War. In 1917, the force was
relieved of its duties in the Prairie provinces. The remaining 300 officers
feared they would be disbanded if they didn't find some new reason for
existing.

At exactly this perilous moment, laws banning alcohol and other drugs were
popping up all over Canada. The Mounties seized the lifeline.

In the turf wars that followed, the disorganized doctors were brushed aside
and the RCMP took control of Canadian drug policy. As in the U.S.,
maintenance and other medical practices that blurred the line between legal
and illegal were wiped out.

Instead, the line was sharpened: Drugs became "evil" and those involved
with them were, in the words of the RCMP commissioner, "the peculiarly
loathsome dregs of humanity." The only acceptable approach was tough
enforcement and stern punishment. The cops' victory over doctors was total.

In 1961, the Canadian government entrenched the American model.

Canada's new Narcotic Control Act created a mandatory minimum sentence of
seven years for importing heroin, marijuana or other drugs. The maximum
punishment for selling drugs was raised to 25 years from 14. Addicts caught
in possession of drugs could be given an indefinite sentence in a
specialized treatment facility, meaning they would only be released after
they had been "cured" -- in the case of first offenders, the indefinite
sentence was limited to 10 years.

But soon after the law passed, marijuana use and trafficking exploded. In
1955, there were eight convictions for marijuana possession; in 1961, there
were 17; in 1970, there were 5,399; in 1972, 10,695. The use and
trafficking of heroin and other drugs also rose rapidly. Countless
punishments were meted out, but contrary to all expectations, they had no
effect on the rising flood of drugs, addiction, crime and misery.

In 1969, a bewildered government created the LeDain Commission to
investigate Canada's drug policies. Although the commission is most famous
for recommending the legalization of marijuana possession, it also called
for a heroin maintenance trial project. It was ignored.

In Britain, meanwhile, pressure from the U.S. government and a growing
acceptance of the American view that heroin was inherently evil put the
whole system in jeopardy. A new act in 1968, and another in 1971,
effectively shut down the British system.

"It stopped GPs from prescribing," says Cindy Fazey, formerly a
high-ranking official in the United Nations Drug Control Program and now
professor of drug policy at the University of Liverpool. "Doctors could
only prescribe if they had a licence from the Home Office. And that licence
was only given, with one or two exceptions, to consulting psychiatrists who
were in teaching hospitals and had clinics for alcoholics."

As in the United States, abstinence became the overriding goal and by the
late 1970s a minuscule fraction of addicts was being prescribed heroin.

The fall of the British system brought the rise of the black market. By
1984, Britain had as many as 75,000 addicts -- many of them unemployed,
homeless, unhealthy and living by petty crime. Today, Britain has 240,000
addicts and the black market is bigger and more violent than ever. The
Blair government, which has generally taken a hard line on drugs, has
nonetheless announced plans to restore much of the old British system.

Dr. Wouter Barends hardly comes across as a dangerous revolutionary. But
some consider the Dutch doctor's work so subversive and dangerous it has
been denounced by the United Nations and the White House.

"We are looking at the older addicts as chronic patients," Barends says. "I
compare it to schizophrenia, for instance.

"It starts at a young age, some people recover, but for the majority it
becomes chronic. Where it is chronic, people can lead a pretty normal life
with medication and care. It's about the same situation with addicts. They
are sick people. They are chronic patients. They need medication and care
and then they can lead a reasonable life."

The medication he has in mind is heroin. Many addicts can be helped off
drugs, he says, but some can't. "Then we come to the situation where we say
we'll provide care for these people. Not a cure, but care."

Dr. Barends, an addiction specialist for 20 years, is senior public health
doctor with Amsterdam's public health department. He runs the MSU where
patients such as Marion get free daily doses of the drug that has terrified
much of the western world for 90 years.

Opposition to such clinics has been fearsome. John Walters, the White
House's top anti-drug official, wrote in the Wall Street Journal that
patients at these clinics, far from being "productive citizens," are
"demoralized zombies seeking a daily fix."

In response, Barends points through the window of a meeting room where a
seemingly ordinary woman in her late 30s talks with a counsellor. "Does
that look like a zombie to you?" he asks, grinning.

Heroin use is an odd thing. Most people who take the drug do so for a short
time, or sporadically, and never become addicted. Of those who get hooked,
most stop using the drug without any formal treatment within a few years.
Of the rest, most can ultimately be helped off the drug with treatment or
at least be stabilized with regular doses of heroin's chemical cousin,
methadone.

Just a small fraction of users ultimately falls into the classic profile of
a broken-down junkie whose addiction keeps a fierce grip as years and
decades crawl by. Unfortunately, that fraction tends to be made up of the
addicts who are most damaged and alienated. They tend also to be the
heaviest users of heroin and the likeliest to commit crimes to pay for
their drugs. They are the wretched of the inner cities, the junkies who
populate the ghettoes, prisons and morgues.

In Amsterdam, there are roughly 5,000 addicts. Due to Holland's generous
social welfare system and extensive treatment services, the majority are
"in pretty stable conditions," says Barends.

Most take prescribed methadone or other treatments. They have housing,
decent health care, and regular contact with officials -- a key reason why
Holland has one of the lowest rates of drug-related deaths in the western
world.

Only about 10 per cent of Amsterdam's addicts live in more chaotic
circumstances: hustling, often homeless, living at the extreme margins of
society. These addicts have repeatedly fallen through the cracks of
treatment and social services. They are the last-chancers who become
Barend's patients.

In 1998, the Dutch government opened the first maintenance clinics in
Amsterdam and Rotterdam. Others opened later in four more cities. About 600
addicts are now enrolled.

For the first three years, the program operated as a carefully constructed
experiment. Eligible patients were randomly assigned either to a group that
received methadone only or another that got methadone and heroin. Both
groups were also given medical care and counselling.

On entering the program, patients sat through a battery of interviews about
their lives and behaviour. Every two months, a team from outside the
program did new interviews. A central committee collected and reviewed the
results.

Patients were evaluated in four categories: physical health, psychological
health, contact with non-drug users, and crime. To be counted as a
"responder" -- a success -- a patient had to show at least a 40-per-cent
improvement in one category, no increase in drug use, and no decline in any
category.

The results were unequivocal. In the group given methadone only, "about 20
per cent were responders," says Barends. But in the heroin group, "55 per
cent of people were responders." Of the biggest success stories -- patients
who showed major improvements in two or more categories -- virtually all
were from the heroin group.

A sub-study looked at what happened when the heroin -- but not the
methadone -- was cut off. Within two months, 80 per cent of responding
patients lost all the gains they had made. The clinics put these patients
back on heroin maintenance, Barends says, because "if you have a good
treatment it's not ethical to stop it."

Guido Vandervet was among those placed in the heroin group, a rare bit of
luck in the life of the 42-year-old junkie. More than two decades spent
scrambling to feed his addictions to heroin and cocaine have left his face
drawn and his body thin and haggard. Still, he's looking better than he did
in the past.

At the lowest point, he says, "I was 45 kilos (about 100 pounds). I was
near to death. I didn't eat at all. I was so crazy I lived in a closet in
my house. I was convinced the police were under the couch."

After Guido started getting heroin from the MSU and he gave up the
relentless hunt for money and drugs, his weight shot up to 155 pounds.

With his new free time, Guido works on a computer at a drop-in centre for
addicts in Amsterdam. When the MSU made a video about the program, Guido
produced the graphics for the introduction. "It was an animation of a
syringe and things like that. And I got good money for that."

His income these days comes from odd jobs and welfare. He has put petty
crime behind him, he says.

CANADIAN STUDY WOULD PRESCRIBE HEROIN IN THREE MAJOR CITIES

Encouraged by results in Europe, Dr. Martin Schechter, chair of
epidemiology at the University of British Columbia, and a group of
colleagues want to try the same in Canada. The North American Opiate
Medications Initiative (NAOMI) will prescribe heroin through clinics in
Toronto, Montreal and Vancouver.

"The core of the study is that about 210 people will be assigned to the
medical heroin arm and 210 people will be assigned to the methadone arm,"
says Schechter. "These people have to be chronic heroin addicts, that means
at least five years of addiction. They have to have tried the best therapy
at least twice in the past. And they have to be currently using heroin,
which means obviously that the methadone in the past was not ultimately
successful."

In November 2002, a House of Commons committee recommended the NAOMI study
proceed. Only the Canadian Alliance members of the committee dissented.

"We're supposed to find a strategy to combat illicit drug use and I get
very frustrated when I see white flags waving all over the place and people
in retreat mode," says Kevin Sorenson, one of the dissenting MPs. Instead
of a study on heroin maintenance, the Alliance called for "a pilot project
to develop detox and rehabilitation centres."

Schechter thinks the critics are fooling themselves. Research on treating
heroin addiction has been going on practically since heroin was invented
over a century ago. And detox and rehabilitation centres have existed
across the country for decades, along with methadone programs.

"We have to accept the reality," Schechter says. "There is a subset of
people with heroin addiction who repeatedly are not successful" in treatment.

"Those people, although they represent a minority of people with heroin
addiction, probably contribute a large proportion of the public disorder
and criminal problems associated with addiction. It's very important we try
to reach out with new ways of getting these people into some form of therapy."

With maintenance being re-discovered in country after country, hardliners
in the UN and the White House are doing their best to discredit the idea.

John Walters, the U.S. drug czar, attacked the British system in the Wall
Street Journal last year.

"When British physicians were allowed to prescribe heroin to certain
addicts, the number skyrocketed," Walters wrote. "From 68 British addicts
in the program in 1960, the problem exploded to an estimated 20,000 heroin
users in London alone by 1982."

This is deeply deceptive, says Fazey. Not only had the British system been
in place for decades before 1960 without any increase in addiction, it was
effectively dead "by about 1972."

American attacks on heroin maintenance are particularly ironic given it was
the U.S. that pioneered another successful form of maintenance.

Methadone is a synthetic opiate chemically related to heroin. It is just as
addictive as heroin but it doesn't cause a high if used as directed by a
physician. And unlike heroin, it can be taken orally and lasts for a full
day. In the 1960s American researchers showed that many heroin addicts
could be stabilized and lead a normal life while on methadone. In the
1970s, methadone became standard treatment in the U.S., Canada and elsewhere.

But methadone maintenance was controversial at first for exactly the same
reason heroin maintenance is now: It involves giving an addict a steady
supply of the drug to which he is addicted.

The difference is purely image, Schechter says. Methadone is seen as just a
drug, a medicine, something that can be used constructively under a
doctor's supervision. So are others in the opiate family. "Demerol,
morphine, and Tylenol 3 with codeine are drugs. But heroin is 'evil.' That
doesn't make sense."

The Swiss broke this taboo when they experimented with heroin as medicine.
The Dutch followed. Canada, Britain and others are set to do the same. With
time and continued success, the physicians behind the heroin maintenance
projects may restore an old medical technique.

Schechter thinks this process is already far along.

"In Canada, we are discussing trying things, like safe injection sites,
like medically prescribed heroin trials, that we would never have dreamed
of talking about five or 10 years ago. And I will predict this will
continue, and we will eventually, I don't know when, but the issue of
decriminalization and the conversion of drugs into a public health and
medical situation will be on the front burner in this country in the future.

"That debate will occur. There is just no escaping it."