FREE JUNK FOR JUNKIES

In What May Seem Like a Bizarre Notion, Canada Is Getting Ready to Prescribe Heroin to Addicts In Three Major Cities

"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,
looking less like the thoughtful 44-year-old she is than a kid at Christmas.

She catches herself and smiles. "For other people, these are little
things. Normal, daily things. But for me, it's heaven."

Marion 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 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. "Around and around and around. You see yourself
going down and down. It's horrible."

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 "10 times, 20
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 on a side
street in central 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. The whole
process involves little more fuss than a diabetic stopping by to take
insulin.

Like most veteran 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." For the first time in decades, she is free to do
something other than hustle and that freedom "is the difference
between night and day."

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

That's certainly what Marion's family thought. "In the beginning, it
was, 'What? Is the government crazy?' " But the positive effects the
program has had on Marion are unmistakable. "Now they really see a
change," she says, and 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.

International Trend

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 satisfying 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 greatly 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 it's a revolutionary new idea. It's not. The
ongoing 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. In Britain, maintenance
survived criminalization and remained standard practice until the late
1960s.

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 are fighting back.

With His Bright Blue Eyes, Soul

patch and a low-key voice that would do well on late-night FM radio,
Dr. Wouter Barends hardly comes across as a dangerous revolutionary. A
beatnik, maybe, but not a bomb-throwing radical. But some consider the
Dutch doctors' work so subversive and dangerous it has been denounced
even from the lofty pulpits of the United Nations and the White House.

"We are looking at the older addicts as chronic patients," Dr. 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 Dr. Barends 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. From a tiny
office, he runs the MSU where patients like Marion get free daily
doses of the drug that has terrified much of the western world for 90
years.

Opposition to clinics such as Dr. Barends' 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."

When I read Walters' words to Dr. Barends, he jumps to his feet and
takes me down the hall. He points through the window of a meeting room
where a perfectly 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 remainder, most can ultimately be helped
off 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 disturbed, 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 spectres on street corners, the junkies who populate
the ghettoes, prisons and morgues.

Stable Conditions

In Amsterdam, there are roughly 5,000 addicts. Thanks to Holland's
generous social welfare system and extensive treatment services, the
majority are "in pretty stable conditions," says Dr. 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
Dr. Barends' 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 currently enrolled in the whole country, 150 in
Amsterdam, although that's not enough to meet the need. "We need
places for about 400 people still," says Dr. Barends.

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 conducted 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 Dr. 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, Dr. 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. 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 gave up the
relentless hunt for money and drugs, his weight shot up to 70
kilograms. "I even got my veins back," he laughs.

With his new free time, Guido works on a computer at a drop-in centre
for addicts in Central 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
finally put petty crime behind him, he says.

A few in the program are doing even better. "Four of them got a steady
job doing garbage collection," Guido says. "And they wanted to get a
driver's licence really bad. But you have to be clean. You can't smoke
drugs if you're behind the wheel of a truck. So they quit with
everything. And from the four, only one got fired. And they're working
there already for three years now."

Swiss doctors reported similar results when they experimented with
heroin maintenance in 1994. In the first two-year phase of the
project, patients showed major improvements in physical and mental
health; homelessness dropped to one per cent from 12 per cent ;
permanent employment jumped to 32 per cent from 14 per cent. Within 18
months of starting treatment, the percentage of addicts relying on
crime for income plummeted to 10 per cent from 70 per cent.

The Swiss also found that while some addicts will continue taking
prescribed heroin for years, most eventually move on after they get
some order and stability in their lives. Of the addicts first enrolled
in 1994, just one-third were still getting heroin in 2000. Of those
who moved on, more than a third switched to methadone treatment, while
one in five gave up drugs altogether.

Saves Tax Dollars

Swiss researchers also calculated that the cost savings resulting from
reduced crime and addicts' improved health meant the program actually
saved tax dollars. The Swiss government, satisfied that heroin
maintenance works, made it a permanent feature of the health-care system.

But critics complained, correctly, that the design of the Swiss study
was not up to the toughest scientific standards. Hardliners in the
U.S. government and United Nations dismissed the results.

Knowing this, the scientists who created the Dutch study designed it
to avoid the flaws in the Swiss research. "And it basically confirmed
what the Swiss had found," says Dr. Martin Schechter, an AIDS
researcher and the chair of epidemiology at the University of British
Columbia. "So the combination of the two studies is much more positive."

Encouraged by results in Europe, Dr. Schechter 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. 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."

Alliance Opposed

In November, 2002, a House of Commons committee recommended the NAOMI
study go ahead. 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."

Dr. 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," Dr. 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 that we try to reach out with new
ways of getting these people into some form of therapy."

But there seems to be more to Sorenson's opposition to heroin
maintenance than a simple disagreement about what works. It appears in
his response to the common argument that heroin maintenance is no
different than giving insulin injections to diabetics. Sorenson is
offended by that analogy. "It's not just like diabetes. This is a
self-inflicted disease. What are you telling people?"

Much as Dr. Schechter and other researchers would like to deal with
addiction as a matter of science and medicine, many feel it is also a
moral issue. Illicit drugs are inherently evil, so giving them to
addicts is wrong no matter what the practical consequences. 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 enter a criminal subculture to
maintain a habit and so addiction rarely led to a life in ghettoes and
gutters. On the contrary, the Victorian stereotype of an addict was a
bored, middle-class housewife.

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. In the
1870s, Eduard Levinstein, a Berlin physician and pioneering addictions
researcher, distinguished between the two, praising the addict who
works diligently at his "art and profession" and "fulfils his duties
to his government, his family, and his fellow citizens in an
irreproachable manner."

These attitudes shaped how doctors treated addiction. Much research
into breaking addiction was done and many doctors struggled to get
their patients off drugs. But doctors also knew that 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. Physician, 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.

Moral Reform

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 merely 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.

But the reformers, and the criminal prohibition they enacted,
succeeded in changing how drugs were seen. Drugs were no longer a
health issue. They were a criminal matter. Law enforcement officials
became key figures in drug policy and the police naturally drew a
bright line between the legal and illegal. Drugs were simply
contraband, criminal, evil. The context of a drug's use was irrelevant
because the law doesn't make exceptions for evil. Illegal drugs must
simply be wiped out.

In 1916, the United States Justice Department declared that
maintenance was not a legitimate medical practise and therefore was
illegal under the Harrison Narcotics Act of 1914. Doctors were furious
and loudly protested, but to no avail.

The Justice Department was adamant, in part because the lawmen
believed a new solution for opiate addiction had been developed: An
American insurance salesman had convinced top U.S. officials that his
tortuous five-day regimen involving belladonna, castor oil and
strychnine could cure any addiction. Most physicians thought this was
nonsense -- one critic dismissed the alleged cure as "diarrhea,
delirium, and damnation." Only years later did government officials
acknowledge the cure was a fraud, and by then, maintenance was dead
and buried.

In 1919, the U.S. Supreme Court agreed with the Justice Department, in
a 5-4 decision, that maintenance was not a legitimate medical
practice. The court didn't bother to say why it ruled as it did. To
call maintenance medical treatment, the majority declared, is "so
plain a perversion of meaning that no discussion of the subject is
required."

By 1920, as historian David Musto wrote in The American Disease,
"advocacy of maintenance was repressed as sternly as socialism."
Doctors and pharmacists were arrested. Clinics doing the same work
that the Swiss and Dutch would experiment with 70 years later, with
the same results, 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. The criminal dealer "finds himself in
clover," lamented the Illinois Medical Journal in 1926, while "the
doctor who needs narcotics used in reason to cure and allay human
misery finds himself in a pit of trouble." Within a decade of the
criminalization of drugs, maintenance had vanished from the United
States and was soon forgotten.

'Barbarous and Inhumane'

In Britain, everything was different. 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 American 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."

Another called the American abolition of maintenance "barbarous and
inhumane." Doctors must be allowed to treat patients as they and their
professional association saw fit. The police should have nothing to
say about it.

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
that 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, including general
practitioners.

Most maintenance prescriptions were for heroin or morphine, but
doctors occasionally prescribed marijuana and cocaine. In one
documented case, a physician introduced to cocaine in 1900 "was still
receiving about 500 milligrams daily at his death aged almost one
hundred," writes historian Richard Davenport-Hines.

Like the United States and Britain, Canada faced the maintenance
question when it, too, criminalized drugs. At the time, Canada was a
loyal son of the British Empire but still this country chose to follow
the American model -- for reasons that had little to do with
principles or evidence and much to do with institutional power.

"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 of 1914-18." 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 and 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 time of 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 quickly took control of Canadian drug policy. As in
the United States, 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 the
doctors was total.

Only three decades later, in the early 1950s, did the issue surface
again. Canadians panicked over stories of a heroin epidemic centred,
then as now, in Vancouver. Whether there ever really was a surge in
use is debatable, since the only evidence seems to be scary newspaper
stories and the excited claims of police and politicians. Still, the
fear was real. And so was the debate that followed.

Not a Crime

In 1952, a Vancouver committee chaired by Dr. Lawrence Ranta
concluded, "North American efforts at control have been spectacularly
ineffective in reducing drug addiction, drug traffickers, and the
thieving and moral degradation that supports the illegal drug trade."

The committee demanded that addiction be treated as a disease, not a
crime, and addicts seen as patients, not criminals. In particular, the
committee recommended Canada reject the American model and adopt a
heroin maintenance program similar to the British system.

In 1955, a Senate committee came to the opposite conclusion. The
British system wouldn't work in Canada, the committee insisted,
because Britain had just a few hundred addicts compared to Canada's
3,200, so "the situation there is not comparable to that of Canada."

The senators were instead quite taken by the testimony of Harry
Anslinger, the top American drug official who claimed a clear
correlation between the severity of punishments and the amount of drug
use. Tougher sentences were needed across the board, the senators
concluded. The committee also recommended addicts be forced into
treatment in special facilities -- "drug farms" similar to those that
had operated in the United States since the 1930s, with dreadful results.

The senators apparently didn't notice that the British situation
blatantly contradicted Anslinger's thesis that less punitive laws
caused more use. Nor did they think it strange that the United States,
which had recently toughened its already severe sentences, had by far
the highest rates of drug use in the western world -- another obvious
contradiction of the Anslinger argument.

Finally, in 1961, the government made its decision: It rejected the
British system and further entrenched the American model. The 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.

The new act accomplished nothing. Very shortly after the law passed,
marijuana use and trafficking exploded. (The year the Senate committee
reported, 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 draconian 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. On that point too,
the commission was ignored.

How might things have been different if the government had followed
the British lead? That will never be known, of course, but an
intriguing hint lies in an obscure survey of 25 Canadian addicts
living in Britain in the 1960s. All the addicts had been hooked on
junk for many years in Canada before moving overseas. And all had
received heroin maintenance in Britain.

Startling Changes

The survey found the move from Canada's punitive approach to the
British system produced startling changes. In Canada, only two of
those surveyed said they worked steadily while addicted. In Britain,
13 had full-time jobs and four worked part-time; six of the full-time
employees had been working at the same job for three or more years.

In Canada, 20 of those surveyed "moved about often to avoid detection
and arrest." In Britain, 10 had been living at the same residence for
two or more years when they were interviewed and eight had been in one
place for one to two years. None was homeless.

In Canada, the respondents' average number of criminal convictions was
7.3 and they had spent an average of 6.7 years in prison; only two of
the 25 respondents had never been convicted of a crime. Many of these
offences were drug crimes, including possession and dealing, but by
far the most common crime was theft. In Britain, 12 of the respondents
had never been convicted of a crime, while five had been convicted
once.

These results, compelling as they are, likely understate the impact of
heroin maintenance because the Canadians involved had already spent
years in a criminalized heroin subculture. For most addicts in that
environment, lying, cheating and stealing become second nature. And
old habits die hard.

British addicts who got heroin maintenance from the beginning of their
addiction were never forced to enter a criminal subculture or learn
criminal habits. As a result, they were often very ordinary people,
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.

In 1966, while working on her PhD, Fazey worked at a heroin
maintenance clinic in Birmingham. "It was just a normal part of their
lives. Just as a diabetic needs to inject, so a drug addict does. They
were holding down jobs. There was an architect. A computer programmer.
The ones with disorganized lives tended to be disorganized anyway and
actually the prescriptions added some organization and stability."

The police, too, treated addicts as sick people, not criminals.
"Addicts would not be hassled as long as they were straight and didn't
deal," says Fazey. "The relationship between the addicts and the
police was extremely good. There was one occasion where a couple were
chucked out of their lodgings on a Sunday morning because the landlord
found out they were addicts. They immediately phoned the drug squad
and said, `Help!' And the drug squad came and told the landlord they
were OK, they are under treatment, they were not a problem." They got
the apartment back.

A tiny portion of prescribed drugs was sold illegally into a "grey
market" but there was virtually no drug smuggling in Britain and no
"black market at all," says Fazey. With addicts receiving their drugs
from doctors, there simply wasn't enough demand to boost the price of
street drugs and generate the profits that lure criminals into
trafficking. Hard as it may be to imagine today, impure, untested,
illegal heroin simply could not be found on British streets.

Nor did maintenance result in doctor's offices spilling over with
addicts. For decades, the number of British maintenance patients stood
between 300 and 600.

With tiny numbers of addicts living relatively normal lives, and no
criminal black market at all, Britain offered an alternative to the
punitive approach that had dominated North America since the 1920s.
Throughout the 1950s, American and Canadian reformers constantly
pointed to the superior results in Britain, to no avail. The criminal
justice approach only got stronger.

Worse, the British system itself came under attack. In the mid-1960s,
British baby boomers turned to heroin and other drugs in unprecedented
numbers. The same trend swept many western countries regardless of
their drug policies but many British politicians and newspapers
claimed it was entirely the result of a few doctors in London who
seemed to be handing over prescriptions to anyone who asked.

At the same time, 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 Fazey.
"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."

Moral Attitude

Many of the psychiatrists, with little or no experience with opiate
addictions, "had gone to a rather moral attitude of, why should we
indulge you?" Fazey says. 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.
In 1969, Fazey was working in the Home Office when the head of the
drugs branch "called me into his office and said hey, look at this. He
opened his drawer and there's this little plastic bag. And that was
the first time we'd seen illegal heroin."

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.

With maintenance being rediscovered 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
that it was the United States 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. American researchers realized that
makes it ideal for maintenance and in the 1960s they 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
United States, 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. So why is methadone
maintenance accepted today as legitimate treatment while heroin
maintenance is hotly controversial? Dr. Martin Schechter insists it
has nothing to do with the properties of the drugs themselves.
"They're both opiates," he says. "They're both highly addictive."

Old Medical Technique

The difference is purely image, Dr. Schechter says. Methadone is seen
as just a drug, a medicine, something that can be used constructively
under a doctor's supervision. So are the 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 a valuable old medical technique.

And they may do more than that. They may also advance the idea that
drug policy should not be about criminalizing users, demonizing drugs
and trying, futilely, to wipe out the drug trade. Instead, drugs would
be dealt with strictly as a health issue. Old taboos would be junked.
The police would cease to lead the discussion. Whatever could be
proved to promote human well-being would be done, no matter how odd it
may sound at first -- even giving junk to junkies.

Dr. 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."

The doctors are fighting back.

Marion, Guido and the other heroin maintenance patients at the
Amsterdam MSU have their own struggle now that they no longer have to
spend every waking moment hustling for heroin: How to live a normal
life.

As a junkie living at the margins of society, Marion says, "you also
get addicted to stealing or whatever. If I see something expensive I
still have to watch myself that I don't, by reflex, put it in my
pocket. It's so ingrained."

Not only do old habits have to go, new ways to fill the day have to be
found. New patients in the program "don't know what to do with their
time," Guido says. "And some use more coke than they used to. Or some
start using coke because they're used to going to the dealer. But
after half a year, they settle down. They start doing normal things.
Get a job. Contact the family again."

For those who have been addicted for decades, it truly means starting
over. "I have to relearn things I learned as a child," Marion says.
"It's the little things. Getting up on time. Being on time at your
job. Taking care that you eat. Even things as simple as looking
somebody straight in the eye. I still think that people see a junkie."

When Marion describes the challenges she faces, she doesn't sound
daunted so much as eager, even excited. "I have hope again," she says,
her eyes wide with amazement. "If I have a computer, maybe I can fit
my way back into society."

The computer again. She can't stop talking about the computer. Just
like a kid at Christmas.