FIXED UP

When nothing else works, heroin addicts should be prescribed the drug
they crave, says Clare Wilson

PAY A visit to William Shanahan's clinic in central London and you may
see some strange goings-on. He hands out heroin to junkies. Shanahan
is one of a small number of doctors in Britain who hold a licence to
prescribe heroin to State-registered addicts. In his experience it's
the best way to deal with the really tough cases-those hardest of
hard-core addicts who repeatedly relapse after conventional treatment.

Elsewhere, too, doctors are experimenting with heroin as a treatment
for heroin addiction. Switzerland currently doles out heroin to more
than 1000 addicts. Germany has allowed the practice on an experimental
basis. Denmark, Spain, Australia and Canada are considering trying it.
And the Netherlands has just completed two big clinical trials
comparing heroin with the current therapy of choice, methadone.

At the moment such programmes are small scale or experimental. But
they won't stay that way. The Netherlands government, for example,
intends to make heroin prescription a central plank of its drug
policy. Even in Britain, traditionally conservative on drug issues,
heroin prescription is moving up the political agenda. MPs on the Home
Affairs Select Committee are putting the finishing touches to a report
on drug policy. It's due out in the next few weeks, and insiders say
it's likely to recommend wider use of heroin.

So why the groundswell of enthusiasm for heroin prescription? The fact
is, existing treatments for cleaning up heroin addicts aren't good
enough. They leave a persistent core of junkies who simply cannot kick
the habit. There's an urgent need for alternative therapies to help
these people, and heroin prescription seems to fit the bill: recent
research suggests that it helps these addicts stay healthy and cuts
crime.

The reason people descend into heroin addiction in the first place is
that the drug makes them feel good. From the moment it enters your
veins, you experience a warm rush of pleasure that quickly takes you
over until you don't care about anything else. "You're wrapped in
cotton wool, and you haven't got a care in the world," says former
heroin addict Andy King, now a drug counsellor in London. Your brain
turns the heroin into morphine, which stimulates the receptors for
endorphins--natural chemical messengers that damp down pain signals
and lift mood. Heroin is so good at mimicking endorphins that
emergency rooms in Britain and a few other countries dispense heroin
to accident victims as a painkiller.

But the brain gets accustomed to heroin all too easily, so regular
users start to need ever larger doses to achieve the same effect.

Eventually their neurons only function normally in the presence of the
drug. After only a few weeks on heroin, users are prone to severe
withdrawal symptoms-nausea, stomach cramps, muscle aches. These lead
to an almost irresistible urge for more heroin. Most addicts need two
or more fixes a day.

A majority of heroin addicts suffer serious health problems. The main
ones come not from the drug itself but from the unhygienic conditions
they take it in. Sharing syringes spreads HIV and hepatitis, and dirty
needles cause abscesses and blood or heart valve infections. Some
batches of heroin have been contaminated with potentially deadly
bacteria. The drug can also be dangerous in its own right. Users have
no reliable way to test the concentration of a batch, and so
occasionally overdose by accident.

The black market nature of the heroin trade also makes it a major
social ill. A typical habit costs about UKP 160 a day, which helps
explain why users find themselves drifting into theft and
prostitution. A recent British study into drug use and crime found
that 3 out of 10 people who were arrested by the police were opiate
users. And while that's not proof of a link between crime and drugs,
it's highly suggestive of one.

At present there are two main escape routes from heroin addiction back
into mainstream society. Addicts can either volunteer for treatment,
or be forced into it by the courts. The standard treatment is
methadone, in the form of a sugary green drink. Methadone hits the
same brain receptors as heroin but is much sloweracting. That means it
staves off withdrawal symptoms but doesn't produce much of a high.
Users only need a once-daily dosehighly convenient, when addicts must
take it under the doctor's nose. And the lack of a kick also makes
methadone socially acceptable, as no once can suggest doctors are
enabling their patents to get high.

The idea is that methadone frees addicts from the worry of finding
their next fix, so they have a chance to sort out their lives. The
first step is to get stabilised on a fixed daily dose. Then when
they're ready, addicts can be weaned off till they're clean.

But methadone programmes aren't popular with heroin addicts, partly
because the drug doesn't give them the high they crave. Many patients
top up their dose with street heroin, a practice that often gets them
kicked off the programmes. Then there's the methadone itself.

The sugary mixture it comes in makes it too sticky to be injected, so
long-term users often have bad teeth, and diabetics have difficulty
using it. Worse, methadone is addictive, and withdrawal-when it is
eventually faced-is more protracted than with heroin. And it's easier
to overdose on methadone than on heroin (New Scientist, 1 October
1994, p 36). Many users complain that the health system has got them
addicted to a drug that's worse than heroin.

"It's far worse coming off methadone than heroin," recalls King. "It
feels like it gets into your bones. The worst is over within about
five days, but it took me about six weeks to feel like I had a night's
sleep. I came off drugs despite methadone, not because of it."

Another reason some addicts fail on methadone is that they crave the
physical sensation of sticking a needle into themselves. lan Guy, a
Middlesborough doctor specialising in drug addiction who has applied
for a licence to dispense heroin, says one of his patients is so
desperate to inject that after swallowing his oral methadone under
supervision, he secretly spits the dregs into a container to draw up
into a syringe.

Estimates vary as to how many addicts flunk methadone programmes, but
it's not unusual for half to three-quarters of patients to test
positive when their urine is analysed for heroin. "People who cannot
or will not settle on oral methadone alone will carry on injecting
whether you like it or not," says Shanahan, who works as a
psychiatrist at the Chelsea and Westminster substance abuse service in
London.

These problems have prompted a search for alternatives. Some doctors,
for example, are experimenting with injectable forms of methadone,
which many users feel satisfy their cravings better than drinking it.
There's also a new drug on the market, Subutex (see "A new cure?", p
37).

The most radical alternative is to give addicts heroin itself. British
doctors have been allowed to do so since 1926, though the vast
majority choose not to. The first country to try it systematically was
Switzerland. It has pioneered experimental clinics where registered
addicts can get carefully monitored doses of heroin, which they take
under medical supervision. There are now over a thousand addicts in
these programmes, usually getting several fixes a day. About a third
of them use oral methadone as well to stave off withdrawal while their
clinic is closed overnight.

Research shows that the number of patients who admitted being involved
in crime fell from 70 per cent when they started the scheme to 10 per
cent after 18 months. Jurgen Rehm, director of Zurich Addiction
Research Institute, who carried out the study, says he now considers
heroin prescription an essential treatment option. "These are people
who repeatedly fail on methadone programmes," he says. "If they're not
helped it costs us in terms of criminality and their health problems."

The Swiss heroin trials attracted the attention of addiction
specialists elsewhere. But one frequent criticism is that they were
not randomised, controlled trials-the only credible approach to
testing a new medical intervention of this kind, where there's no of
disguising who's getting which drug. In a randomised trial, patients
taking a new treatment are compared with a similar group taking the
old one and patients have no choice of which treatment they get.

But two large, randomised trials of heroin prescription have now been
done. Started by Dutch doctors in 1998 at the request of their
government, they involved a total of 549 addicts who had repeatedly
failed methadone programmes. Around half got heroin plus methadone,
and the rest just methadone.

The trials ended last year and the results look promising. In their
final report, published in February, the Dutch team said that after 6
or 12 months, about half of the heroin-plus-methadone group were both
healthier and committing less crime than when they started on the
trial. This compared with 25 per cent of those on methadone alone.
What's more, when those on heroin plus methadone had their heroin
stopped, 80 per cent of them lost all their health gains within two
months. Jan van Ree, professor of psychopharmacology at Utrecht
University, who led the research, says giving addicts free heroin
means "they don't have to decide when they get out of bed in the
morning what they're going to steal today".

Not all drug addiction specialists, though, believe this is the right
thing to do. Clare Gerada is a doctor who runs a methadone clinic in a
rundown area of London. She's doubtful you can repeat the success of a
wellfunded clinical trial in tough, front-line services such as the
one she runs. She says: "Once you move out of research and into the
real world, there's less counselling and support, and the heroin
starts getting sold on."

The main problem is that community clinics lack the resources to stay
open in the evenings and at weekends, so would face pressure to give
out heroin for later use. And that risks creating a black market in
pharmaceutical-grade heroin. The alternative is to give patents
methadone to see them through the night, which they might be tempted
to supplement with street heroin.

Another downside is that if heroin prescription becomes more widely
available, some addicts may not even try to give up. As a safeguard
supporters agree that it should only be offered to long-term addicts
who have repeatedly tried and failed on methadone programmes.

The biggest obstacle, though, is political. To some, it's simply not
acceptable to supply addicts with heroin. Doing so is tantamount to
legalising drugs. The position might be illogical-after all, it's okay
to give junkies a different addictive drug, methadone, and the
long-term objective remains to clean them up. But it's is a powerful
force, especially in the US. A handful of doctors there argue in
favour of trials but it's a losing battle, even within their own
profession. "Many doctors here are ignorant of addiction," says Ernest
Drucker, a professor of epidemiology and social medicine at the Albert
Einstein College of Medicine in New York who is trying to set up a
trial. "They are even hostile to methadone."

There are signs, however, that politicians in Europe are willing to
take on the challenge. Earlier this month the Dutch government
formally incorporated heroin prescription into official drugs policy.
And in Britain, a Home Affairs Select Committee inquiry into drugs
policy has specifically investigated heroin prescription. The report
is still confidential, but one insider told New Scientist it will
recommend clinical trials of heroin versus methadone.

And the new government body charged with improving drug services, the
National Treatment Agency, is drawing up guidelines on heroin
prescription, due out by the end of the year. The agency's chief
executive, Paul Hayes, says the committee wants to examine whether
heroin prescription should be used more widely. At present 400 or so
addicts receive heroin on the National Health Service. The agency
thinks there may be a case for increasing that number.

As doctor lan Guy says: "We have to ask ourselves what we want. 1 want
healthier patients who get their life stabilised. They're going to
make damn sure they get their heroin from somewhere. Rather than some
illegal pusher, I'd prefer if it were me."

[SIDEBAR]

A New Cure?

Prescribing heroin isn't the only alternative to methadone
maintenance. There's a new drug too: buprenorphine, which is sold by
American pharmaceuticals company Schering-Plough as Subutex.

Like methadone, Subutex latches onto endorphin receptors in the brain
and so staves off heroin withdrawal symptoms. But its pharmacology is
subtly different-it binds to the receptor more tightly, yet stimulates
it less powerfullyso has some advantages as a therapy.

First, it's harder to overdose on Subutex because you need a much
bigger dose. Secondly, it binds so tightly to the receptor that it
blocks morphine molecules from attaching. So addicts who succumb to
temptation and take heroin on top of their Subutex don't get high.

Subutex has been available in France since 1996 and other European
countries, including Britain, are starting to experiment with it (see
Map, right).

Many addicts prefer Subutex to methadone. But not all feel it works
for them principally because, as with methadone, they still crave the
high, So Subutex isn't a miracle cure for heroin addiction.

There is also a practical problem. The drug comes in a tablet that
must be dissolved under the tongue for about 10 minutes. Some addicts
pretend that the tablet is dissolving but hold it to the side of their
mouth, to spit out later.

They may then crush and inject it, which gives a better high, or sell
it on. A new formulation may soon be launched that has no effect when
injected.