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Heroin: Fear and Loathing

Direct Health Effects

Sometimes it takes the death of a celebrity to bring home salient points about drugs, and to dispel the myths that surround them. Cory Monteith, a Canadian actor who made his name on the television series Glee, died in July of 2013 in Vancouver of what was reported as a heroin overdose. Almost immediately, a Calgary Herald editor implied that he would be alive today except for Vancouver’s ready supply of illegal drugs. She took particular aim at the city’s safe injection site (InSite) in the Downtown Eastside neighbourhood.[1]

It was swiftly pointed out that InSite is not in the business of selling drugs of any kind.[2] It also became clear after the coroner had done his work that Cory Monteith did not die of a heroin overdose but of a combination of heroin and alcohol.

As a sidebar to the Monteith story, the day after his death, Abbotsford police sent out a public warning.[3] They reported, in response to a sudden rise in overdoses, that there was a surge of dangerously potent heroin in the area. They had found fentanyl in recent supplies of heroin, which greatly increases the drug’s strength. As it turned out, there was no fentanyl found in Mr. Monteith’s body, but the warning was a cautionary tale to all those in the area who might be using heroin.

More recently, Philip Seymour Hoffman, one of his generation’s finest actors, was found dead in his apartment with a needle in his arm, and a large quantity of heroin in the room. There has been a similar outpouring of grief over Hoffman’s early demise and much soul-searching over the fact that he was an admitted heroin addict who had been clean for years. The relapse was perhaps inevitable, but his death should not have been. Experts have noted that a relapse could have been triggered by prescription drug use.[4] As well, a former addict returning to heroin might overestimate his tolerance for the drug after many years. And even a change as to where the drug is used might be dangerous. For example, if an addict is accustomed to using the drug in his car, injecting in a different environment might trigger an overdose. This is known as “conditioned tolerance.” As it turned out, the toxicology report showed several drugs were present in Mr. Hoffman’s body, specifically heroin, cocaine, benzodiazepines, and amphetamine.

Simon Jenkins, a respected columnist for The Guardian newspaper, talks about the double standard that we have adopted toward drug use.[5] His comments are a direct reference to the classism that determines who gets punished for illegal drug use and who does not. He says, “The law … lumps Hoffman together with thousands found dead and friendless in urban backstreets, also with needles in their arms. It treats them all as outlaws…. Offices, schools, hospitals, prisons, even parliament, are awash in illegal drug use. Their illegality is no deterrent.” Then he concludes: “So what do we do? We turn a blind eye to an unworkable law and assume it does not apply to people like us. We then relieve the implied guilt by taking draconian revenge on those who supply drugs to those who need them, but who lack the friends and resources either to combat them or to avoid the law.” Jenkins expresses the hope that high-profile casualties like Hoffman will lead legislators to re-think their position on illegal drugs and change the law.

What is this drug that took the lives of Monteith and Hoffman? Why is it so feared?

Heroin is derived from the opium poppy, and today most of the world’s supply comes from the Afghanistan, Burma, and Colombia. Opium was first synthesized back in 1874 as an alternative to morphine, after it was discovered that some people were becoming addicted.[6] In 1895, Bayer began producing the substance. The company called their new product “heroin” because soldiers (heroes) who used it would charge into battle in the face of live fire. Bayer promoted heroin as non-addictive and sold it as a substitute for morphine and as a cough suppressant. But as the twentieth century wore on, heroin was eventually prohibited in both the United States and Canada.

Heroin has a blood-brain permeability ten times that of morphine, from which it is derived.[7] This means that the drug causes depression in breathing and increased pleasure, and it can block pain signals from the spinal cord. Injection produces an immediate “rush” like an intense orgasm. Then the user feels four to six hours of a “high,” which might include nodding off or periods of very busy, talkative behaviour. Alternatively, some high-functioning addicts show no abnormal behaviour at all.

As noted, it is possible to overdose on heroin, and to die, although by far most cases of death involve more than the one drug, usually a combination of heroin and alcohol. “While it is theoretically possible to die from an overdose of any of these [illegal] drugs alone, in practical terms this is extremely rare.”[8] With respect to heroin, Dr. Carl Hart says, “In virtually every overdose death involving an opioid … some other substance is present. Most of the time it is alcohol.” He recommends a mass media educational effort to inform people of the dangers of these combinations.

Heroin is a powerful painkiller that sedates the central nervous system.[9] It is addictive both physically and psychologically. Withdrawal symptoms include dysphoria (a combination of anxiety, depression, and restlessness), insomnia, muscle aches, and diarrhea. Some maintain that regular use can cause addiction, but others question this seemingly straightforward assertion. Dr. Bruce K. Alexander, retired professor at Simon Fraser University, for example, rejects the claim that all or most people who use heroin (and cocaine) beyond a certain amount become addicted.[10] He points out that when heroin was being used for therapeutic purposes in the nineteenth century, the incidence of addiction never reached 1 percent of the population, and was declining when the drug was banned.

Withdrawal from heroin is commonly depicted as extremely painful and long-lasting, although some say it is similar to a bad case of the flu. We know that heroin withdrawal can be relatively straightforward if the pressures that led to the addiction are relieved. A favourite example is that of Vietnam veterans returning stateside after the war. Soldiers took drugs to help them through the experiences they were enduring in combat. About 50 percent tried opium and heroin, and half of these showed signs of addiction.[11] Most of them, contrary to the fears of the American government, were able to withdraw from the drugs relatively easily upon returning stateside. The stressors that had led to drug use in the first place had been removed, so users were able to control or eliminate their drug use at home.

One common misperception about drug addiction is the notion that addicts are taking drugs for recreational purposes — to have a pleasurable experience, to get “high.” While this may have been the rationale for their first experiment with drugs, once they have become addicted, attaining a “high” is the last thing on their minds. Rather, they are trying to ward off serious withdrawal symptoms so that they can function. As Dr. Nutt points out, “It is quite common for someone to start taking a drug for the enjoyable effects, but once they’re addicted it becomes the only thing that can relieve the intense cravings and unpleasant physical symptoms of withdrawal.”[12]

Dr. Lisa Lefebvre of Canada’s Centre for Addiction and Mental Health (CAMH) made an educational video in response to the Hoffman overdose. In it she addresses the issue of an addict’s ability to choose to use or not use heroin. “One of the biggest misconceptions is that it is a choice someone makes, and unfortunately that’s not the case…. Heroin addiction is an illness.… Thinking of this as a sort of disease of choice has not been helpful in the past because it has put the onus entirely on that person to, with their willpower, treat what is really a medical illness that needs medical and psychosocial treatments in order to improve the outcomes.”[13]

In a seminal ruling allowing the drug injection clinic InSite to continue operating in Vancouver, the Supreme Court of Canada (in a unanimous 9:0 ruling) said that “serious drug addiction is not a moral choice; it is an illness which essentially negates the notion of ‘choice’ altogether.”[14] Chief Justice McLachlin said many addicts “use multiple substances, and suffer from alcoholism.… [T]hese people are not engaged in recreational drug use: they are addicted.”

American jazz legend Billie Holiday’s riff on heroin explains it this way: “If you think dope is for kicks and thrills you’re out of your mind. There are more kicks to be had in a good case of paralytic polio and living in an iron lung. If you think you need stuff to play music or sing, you’re crazy. It can fix you so you can’t play nothing or sing nothing.” She went on to say that in Britain the authorities at least had the decency to treat addiction as a public health problem, but in America, “if you go to the doctor, he’s liable to slam the door in your face and call the cops.”[15]

Negative Effects of Criminalization

A number of negative health effects are also caused by the fact that heroin has been criminalized. These effects can be profound, sometimes life-threatening, and all-but-impossible to alleviate because of the fear of prosecution. The suppression efforts of law enforcement drive the trade underground, where there are no controls over the quality of the drug or its potency. Users are thus consuming dangerously adulterated and dangerously potent heroin, both of which can kill. Users also inject in unhygienic conditions because of a fear of being arrested. Forced to hide from the law, heroin users may inject with dirty, shared needles, using water from puddles, in cold back alleys that make it more difficult to inject into constricted veins. These conditions encourage the spread of deadly diseases like HIV/AIDS and HCV.

One heroin addict in Moscow described the fear occasioned by aggressive drug law enforcement, and the negative effects it produces: “Fear. Fear.… And not only fear of being caught, but fear that you will be caught and you won’t be able to get a fix. So on top of being pressured and robbed [by police], there’s the risk you’ll also end up being sick [from withdrawal]. And that’s why you’ll use whatever syringe is available right then and there.”[16]

Safe injection sites are one way of providing a safe place and safe conditions for heroin addicts to use their drugs. These are places staffed by trained nurses and doctors. Users must buy their drugs from their usual illegal source, but are provided with sterile syringes and clean surroundings in which to inject safely. Should the heroin prove to be so pure that the user begins to show signs of overdose, medical personnel step in to help. Similarly, should the heroin be adulterated with a dangerous substance,[17] they are available to deal with the consequences. The spread of HIV/AIDS and HCV is substantially reduced by safe injection sites because of the hygienic conditions in which the injections take place. As well, used needles must be left at the location, and so are not discarded in public places where they can cause harm to the public.

In Canada, the only safe injection site (InSite) is located in Vancouver. It was established in 2003 in response to the epidemic of illness and death associated with large numbers of heroin-addicted people living in the Downtown Eastside neighbourhood. It was able to operate due to an exemption from criminal prosecution provided by the federal Liberal government. Despite the proven success of InSite, the subsequent Conservative government spent three years and substantial funds to oppose its continuation. Only a direct order from the Supreme Court of Canada in 2011 compelled the Harper government to continue providing the site with its exemption from prosecution.

This case represented a direct confrontation between the hard-line criminal justice approach of the Conservative government and the public health approach represented by InSite. In assessing the evidence presented by both sides of this argument, the Supreme Court concluded that “InSite has saved lives and improved health. And it did those things without increasing the incidence of drug use and crime in the surrounding area. The Vancouver police support InSite. The city and provincial government want it to stay open.”[18] Chief Justice McLachlin noted that this tiny area of Vancouver is home to 4,600 intravenous drug users whose lives are on the line.

InSite said its staff had intervened in 336 overdoses since 2006, and that no deaths had occurred at the facility. It had supervised more than 1.8 million injections since it opened, and oversees an average of 587 injections daily.[19] In 1993, before InSite was opened, two hundred people were dying annually in the Downtown Eastside.[20] A recent peer-reviewed study reported in The Lancet showed that fatal overdoses dropped by 35 percent in the vicinity of InSite in the two years after it opened (from fifty-six deaths to thirty-three), compared to 9 percent in the rest of Vancouver during that same period. In 2011, there were sixty-six overdose deaths in the entire city.[21] Many others were contracting AIDS/HIV, Hepatitis C, and other serious illnesses. Today, British Columbia is the only Canadian province in which the rate of HIV infection is going down.

Importantly, InSite does more than just provide a safe place to inject drugs. Nurses attend to wounds, abscesses, and vein and skin conditions. Clients are treated like human beings and not like criminals. For some, it is the only place they can go where no one is judging them. And it is critical that the clinic provides a point of entry for treatment. There is a detox centre on its premises that claims a 43 percent completion rate for addicts who seek treatment — something addicts are otherwise reluctant to do because it means risking exposure to law enforcement. InSite also provides transitional housing for addicts who finish detox.

Critics of InSite say that “safe injection” is an oxymoron, and that programs like InSite “enable addictions.”[22] Because the emphasis of such a program is on maintenance and disease prevention rather than abstention, many are unwilling to see its value. “Arguably, places like InSite are actually making addictions worse by enabling the drug use and sending the message that its ‘okay’ to use drugs, so long as it’s done ‘safely,’” says one critic. This statement flies in the face of evidence that clearly shows the number of addicts to be falling substantially from harm-reduction programs such as the one in Switzerland.

Critics often fall back on inflammatory language in rejecting the idea of harm reduction. For example, one says that InSite is a “spit-shined flophouse of momentary sobriety” where, “despite any lofty claims, for most addicts, InSite’s just another place to get high.”[23] This critic claims that there has never been an independent analysis of InSite, choosing to ignore the extensive analysis done by the Supreme Court of Canada, among others. He appears to be unaware that even the Vancouver Police Department approves of the program and urges addicts to use the location.[24] Police say that “injecting drugs without close supervision compounds the problem. InSite has been established to reduce that risk.” Opened in 2003, InSite has been visited 1.9 million times and there have been no overdose deaths as a result of its services.

The Urban Health Research Initiative in Vancouver has recently reported some other remarkable improvements that can be largely attributed to harm-reduction programs.[25] For example, in 1996, 39.6 percent of drug users were borrowing needles. In 2011, only 1.7 percent were engaging in this risky behaviour. There have also been dramatic decreases in diseases over those years. In 1997, there were 8.1 cases of HIV per one hundred person years. In 2011, the number was down to 0.37. HCV experienced a similar decrease, from 37.1 cases to 1.1. Fewer people are injecting drugs and more are ceasing use. Incredibly, in 1996, the rate of cessation of injection drug use was 0.4 percent; in 2011 it was 46.6 percent.

Proponents of needle exchange programs like “Cactus” in Montreal (the first of its kind in North America) say that the Supreme Court decision on InSite will let them “stop being hypocrites” if it means that they will now be able to open a full-service safe injection site.[26] As Cactus community coordinator Jean-François Mary said, “For 22 years, we gave people clean tools, then sent them out into the street. We were doing half the work. Now they’ll be able to shoot up in complete safety.”

Unfortunately, it seems that the current Conservative government is trying to make setting up these safe injection sites in Canada a lot more difficult. Proposed new regulations will make it near-impossible to satisfy all the requirements for opening such a facility. Not only will new sites have difficulty meeting these new requirements, but InSite itself will now find it hard to renew its mandate. The federal health minister will now be able to block safe injection sites based upon his or her assessment of “the local conditions indicating a need,” “the regulatory structure in place to support the facility,” and “expressions of community support or opposition.” The fact that the mayor and police chief in Toronto are both opposed will probably weigh more heavily with the current government than the expressions of support by public health officials.[27]

Other cities in Canada are planning to apply for an InSite-style exemption from criminal law so that they can operate safe injection sites as well. At the end of 2013, Montreal had approved four new supervised injection sites, including one mobile unit.[28] With start-up costs of $3.2 million and operating costs of $2.7 million per year, proponents said the program would pay for itself within four years. They claimed that the health care system would be the winner, with reduced incidences of HIV/AIDS, HCV, overdoses, and problems with dirty needles left in public places. However, nothing can happen until Health Canada provides an exemption from criminal prosecution — something that is by no means guaranteed under the new regulations.

Thousands of prison inmates who inject drugs like heroin are also at risk for disease and death. The government has steadfastly refused to allow for a needle exchange program in prisons despite repeated requests by the prison ombudsman.[29] Prison authorities provide bleach for cleaning needles, but this is not a wholly effective method of killing viruses. The resulting rates of HIV/AIDS and Hepatitis C are ten to twenty times higher in the prison population than in the general population. These are serious and even deadly diseases, which are later spread to the community as prisoners are released from incarceration.

Reasons provided by the correctional services for refusing clean needles have no foundation in fact. Prison needle exchanges do not lead to an increase in drug use, do not result in syringes being used as weapons, and do not result in an increase in accidental needle-stick injuries. These three myths have been rejected by the Public Health Agency of Canada.[30]

Needle exchanges are run inside prisons in many countries, including Spain, Moldova, Iran, and Kyrgyzstan.[31] These regimes are not known for their progressive ideas with regard to incarceration, but they do recognize the facts of life, one of which is that inmates will find ways to obtain drugs and inject them.

NAOMI, the North American Opiate Management Initiative, was a program that operated out of St. Paul’s Hospital in Vancouver. NAOMI supervised the administration of heroin to 350 of the “toughest, most difficult to reach narcotic abusers,” according to Dr. Keith Martin.[32] The randomized trial divided addicts into three groups and provided them with heroin, hydromorphone, or methadone. Hydromorphone is a very potent opioid, a derivative of morphine, used to treat chronic pain. It is anywhere from six to ten times as strong as morphine. Methadone is a synthetic opioid that is legal, has been approved for use as an alternative to heroin, and can be prescribed for addicts. In the remarkable results reported by the NAOMI project, users who were resistant to methadone, and to whom heroin was provided instead, were 62 percent more likely to remain in treatment, used less heroin, and committed fewer crimes.[33] They also showed improved employment satisfaction and social integration — all indicators of a return to some version of a normal lifestyle.

In practice, NAOMI patients attend at a facility like Vancouver’s Crosstown Clinic at set times (two to three times a day) and sign in to receive their prescribed heroin. They are turned away if they have been using alcohol. The clinic provides them with a measured dose of pharmaceutical-grade heroin and sterilized equipment. The patients administer the dose themselves in a mirrored room, and then must sit in the lounge for twenty minutes for monitoring so that staff can deal with any negative reactions.

Dave Murray was one of the addicts who was treated with heroin.[34] He says he is living proof that heroin maintenance works. “After more than 20 years dealing and injecting drugs, Mr. Murray participated in the earlier NAOMI trial, where he regularly received doses of heroin without having to worry about his next fix. This new stability erased the stress from his life and prompted reflection, Mr. Murray said. ‘My brain re-engaged, and I made a conscious decision to try detox. I failed at first, but about three years ago, finally I stopped using.’”

Health Canada sought advice from independent experts on the subject of prescription heroin.[35] These experts told Health Canada that this is the only “next step” available for some addicts, and that prescription heroin is a “promising treatment of last resort.” They also said it decreases harm to individuals and to their families. The Health Minister of British Columbia calls prescription heroin “compassionate use of a medication.”

A follow-up study to NAOMI, “The Study to Assess Longer-term Opioid Medication Effectiveness” (SALOME) has been designed to determine the effectiveness of providing hydromorphone to heroin addicts.[36] It involves 322 patients and will be completed by early 2015. It will attempt to show whether or not hydromorphone is as good as prescription heroin at treating the addicts who do not respond to methadone. Hydromorphone treatment currently costs $39 per day, a not-insignificant amount for patients.

The question then arises: why is the government going to such lengths to find a viable alternative to heroin when prescribed heroin itself appears to provide the best results? We know that methadone does not work for everyone, and that some addicts suffer from pain and craving when they take it.[37] As one pharmacist says, “Most addicts loathe it. It is a highly addictive synthetic opiate, more addictive than heroin and harder to withdraw from, but it survives the digestive system and so does not need to be injected.”[38] In other words, addicts are being required to drink “green gunk” largely because legislators appear to have an aversion to the idea of injection, and especially to providing heroin as the best treatment. As Dr. Perry Kendall, British Columbia Provincial Health Officer, says, “In Switzerland and Germany, they don’t have a problem with treating people with heroin, but here we do.”[39]

Doctors in the SALOME project expressed concerns about an exit strategy for addicts who would be leaving the clinical trials. How would they survive if they could no longer rely upon heroin maintenance? The doctors made an application to Health Canada under its Special Access Program (SAP) to enable them to continue with heroin maintenance and Health Canada duly approved prescription heroin (for ninety days after exiting the program) for 21 of the addicts who would otherwise be facing serious, life-threatening conditions.[40]

When this came to light, the Health minister, Rona Ambrose, was swift in her response. She quickly banned what she called “dangerous drugs like heroin, cocaine, ecstasy, and LSD” from being prescribed to patients.[41] And she followed this up by stating that “the prime minister and I do not believe we are serving the interests of those who are addicted to drugs or those who need our help by giving them the very drugs they are addicted to.”[42] She suggested that addicts try alternative approaches like acupuncture.

Five of the affected addicts, together with their health provider, Providence Health Care, and a legal advocacy group have now filed a lawsuit challenging the federal government.[43] The same arguments will be made as were successfully made in keeping InSite open. In that case, the Supreme Court of Canada found that the government’s attempts to close the site were “grossly disproportionate because the potential denial of health services and correlative increased risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on InSite’s premises.”

Larry Love is one of the patients named in the law suit. He describes his life before SALOME as “a life of hell” and claims that the heroin maintenance program has provided him with “vastly improved” health and well-being. He believes it can save lives and allow addicts to become productive members of society.

His voice “quivering with emotion,” Dr. Scott MacDonald of the SALOME project responded to the federal government’s opposition to the program: “As a human being, as a Canadian, as a doctor, I want to be able to offer this treatment to the people who need it. It is effective, it is safe, and it works…. I do not know what they [the federal government] are thinking.” He claims that about 10 percent of those addicted to heroin require heroin maintenance. Of those, about half are able to move to less-intensive treatment or abstain altogether.

Other jurisdictions have already proven the value of similar maintenance programs. In Liverpool, England, for example, Dr. John Marks reported to work at a clinic that offered treatment to drug addicts.[44] This was back in 1982. At his facility, if users did not wish to work toward abstinence, and if they satisfied certain other criteria, they were offered a drug maintenance program instead. This meant that physicians gave users a prescription for their drug (heroin, cocaine, crack cocaine), which they could take to a pharmacy where it would be filled for free. As part of their therapy, they were expected to attend meetings to show they were otherwise healthy and crime-free. If they did not comply, they were dropped from the program.

Dr. Marks thought prescribing dangerous drugs to addicts was silly, and he planned to shut the clinic down and replace it with a psychiatric program that he believed would succeed. However, the success of the drug maintenance program was so convincing that Dr. Marks changed his mind. Addicts in the program remained free of AIDS, and most of them became healthier and obtained jobs. Police reported a 94 percent decrease in theft, burglary, and property crimes around the area of the clinic, and there was a reduction in drug use. Unfortunately, this program was shut down in 1995 despite its clear success. Dr. Marks put this down to the fact that the American television show 60 Minutes aired an episode highlighting the clinic’s work, and that this approach to addiction flew in the face of the American War on Drugs.

Dr. Marks explained his view of drug treatment (aimed at abstinence) versus drug maintenance (aimed at harm reduction and maintenance) this way: “If they’re drug takers determined to continue their drug use, treating them is an expensive waste of time. And really, the choice that I’m being offered and society is being offered is drugs from the clinic or drugs from the Mafia…. [Giving them drugs] doesn’t get them off drugs. It doesn’t prolong their addiction either. But it stops them offending; it keeps them healthy and it keeps them alive.”

Switzerland has also tried different approaches to drug addiction. After the failure of “Needle Park,” a location where addicts could gather and use drugs without fear of arrest, the Swiss opened a number of safe injection sites, which resulted in a reduction in both the number of overdoses and the spread of AIDS. After visiting Dr. Marks’s clinic in Liverpool, Swiss organizers went on to establish the “largest scientific heroin maintenance project ever attempted.”[45] Addicts had to meet a number of conditions before being provided with drugs (either free or for a nominal fee). The final report of the Swiss government was so positive that citizens voted overwhelmingly in a nationwide referendum to continue the program. The report said that the “individual health and social circumstances [of users on the maintenance program, who were “hard-core” drug addicts] improved dramatically, usually in a very short time.” Stable employment increased, unemployment decreased, users learned to function independently, criminal activities decreased dramatically, and costs of medical and social care and crime control dropped by about half.

The Global Commission on Drug Policy reported that in the Swiss program, between 1990 and 2002, the annual number of new heroin users dropped by 82 percent.[46] The overall population of users declined by 4 percent per year during that time, and several areas in Switzerland reported a decrease in injection drug use.

The advantages of a public health approach to heroin use are many. So are the negative effects of its criminalization. Addicts court disease and death by shooting up in back alleys to avoid the law. They must buy their drugs from criminals who specialize in violence, extortion, and corruption. They may commit crimes themselves in order to purchase heroin on the black market. The heroin, controlled by gangs and cartels, may be adulterated with unknown dangerous substances. The purity of the drug will be unknown, so overdoses can result. Members of the community as well as the addicts themselves may already suffer from family breakdown and community disruption caused by drug abuse. These problems are exacerbated by the criminalization of the drug, as addicts are further separated from their families and society by incarceration, and can contract diseases in prison that will then spread outside the prison walls when they are released.

Therapeutic Uses

Despite heroin’s reputation for producing serious addiction and health problems, many credible voices have called for its use as an effective painkiller. As noted earlier, heroin works better for many addicts than methadone because it is more effective at eliminating the pain and discomfort associated with withdrawal. It has also been shown to produce better results in helping patients become drug-free: one study showed that only 1.2 percent of clients became drug-free after using methadone, while 12.5 percent succeeded using heroin.[47]

What about using heroin to treat pain in a therapeutic setting? While legislators and physicians and many members of the public reject the notion of prescribed heroin, in some cases it provides the best remedy for chronic, excruciating pain, particularly for patients who are terminally ill with cancer. The main opposition to the use of heroin comes from those who believe patients run the risk of becoming addicted. Others respond that this concern is not germane, especially if patients are suffering and have only a short time to live.

We also know that people are generally less likely to become addicted when taking the drug for therapeutic purposes rather than for pleasure. According to WHO documents, “research makes it very clear that addiction is a negligible occurrence among patients with no history of addiction who receive opioids for pain.”[48] In one review of such cases, only seven out of twenty-four thousand patients became addicted. The authors say “cancer patients can stop taking opioids when the pain stops; i.e., they do not crave opioids when they no longer need them for pain relief.” They further state that the number one impediment to the medical use of opioids, according to a recent survey of governments, is the confusion and misinformation disseminated on the subject.

Canadian doctor W. Gifford-Jones has been championing the use of heroin for pain relief in terminally ill cancer patients for decades. In 1984, the Ministry of Health finally did legalize the use of heroin for this purpose. However, many restrictions were attached to its use: doctors were required to present their reasons to a hospital committee before permission to prescribe heroin was granted, and the drug had to be kept in a secure location and transported by armed guards. Because the process was so difficult, few doctors prescribed heroin, and ultimately the pharmaceutical company that was licensed to import the drug stopped doing so.

In a recent survey, Canada and the United States were listed in ninth place as the “best place to die.” England, which holds first place, allows prescribed heroin for end-of-life pain.[49] In fact, it has been using heroin for easing palliative pain since the early 1900s.[50]

When the Royal Canadian Mounted Police stated that there was a security risk associated with prescribed heroin, Dr. Gifford-Jones travelled to England to learn about the experience there and to assess these risks. He was told by Scotland Yard that there were few problems, and that hospital pharmacies were never broken into. Rural doctors even carried heroin in their bags for use in emergencies, and he was told that even children dying of cancer were given the drug because it gave them comfort and a “fuzzy” feeling.

Dr. Gifford-Jones emphasizes that the biggest fear of dying patients, especially cancer patients, is the fear of pain. His experience in England confirmed that terminally ill cancer patients do not become addicted to heroin. Why? Because they are taking it for pain relief and not for recreational purposes. Where remission of the cancer occurs, it takes only about three weeks to wean a patient off the drug. Those who claim that morphine is just as effective are mistaken, because heroin is stronger, passes through the blood-brain barrier faster, and provides a comforting euphoria.

Dr. Bruce K. Alexander, professor emeritus at Simon Fraser University, has also determined the efficacy of using heroin for therapeutic purposes. As he says, “conventional wisdom notwithstanding, administering large doses of heroin and other opiate drugs over long periods of time to medical patients does not cause addiction.”[51]

Tom Carnwath and Ian Smith, authors of Heroin Century, also assert that heroin is a more effective drug than morphine in some contexts.[52] Heroin is less likely to produce nausea and itching. It is more concentrated, so less of the drug is needed, which is helpful when injections are required. It gets to the brain faster. Heroin is useful in treating terminal tuberculosis and heart failure, and it is good for treating the cough associated with cancer or influenza in the 15 percent of cases in which patients get very sick if they use morphine. It remains the drug of choice in the United Kingdom when subcutaneous treatment is required.

The authors cite some of the advantages of heroin in detail:

Patients with severe cough and shortness of breath … were undoubtedly very frightened and uncomfortable…. Heroin slowed down the breathing rate and this in itself made patients calmer, even if it did not help their oxygen levels. It is also very effective in suppressing troublesome coughing. On top of this, it is matchless in producing a mental state of calm detachment. Patients remain aware of their pain and illness, but no longer feel it really matters. Much of the horror of illness lies in the fear it induces.

Clearly, the psychological effects of comfort and the easing of anxiety rank high among the advantages of using heroin. As the authors say, heroin, which “even after a hundred years … remains a medicine without superior,” provides “a way of confronting with dignity the challenge of illness and death.” American doctors who have lobbied to be able to prescribe heroin describe it as “the most potent, effective, soluble and rapidly active narcotic ever created.”

Nonetheless, in North America heroin remains unavailable to most patients suffering from extreme pain. Although it is still technically legal to prescribe in Canada, it is in practice not an option. As a consequence, many terminally ill patients are suffering unnecessary pain, fear, and anxiety. Concerns expressed by those who reject the idea of therapeutic heroin should be allayed by the experience in England. As one pharmacist said, “Those politicians who, in the face of all contrary evidence, stubbornly see the drug as the problem are no less misguided than the addicts who see drugs as the solution.”[53]