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A new scientific study investigates the potential benefits of giving hard-core addicts their daily doses
"Heroin saved my life," Darl?ne Palmer says. "Heroin and cocaine. I couldn't deal with reality, so I used them to escape it."
Palmer says she started using at age 11, the result of four years of abuse at the hands of uncles and cousins, and a mother who did nothing to stop it. For the next 27 years she lived the junkie life until she kicked 10-and-a-half years ago. "I was tired of being a professional junkie," she says. "I wanted to die. All the things I dreamed of as a child - friendships, relationships, children - those dreams don't go away when you're a junkie, but they get thrown aside. I knew I had to either stop or die."
Now, as an intervention worker with downtown Montreal needle exchange facility Cactus, she witnesses the familiar spiral so many heroin addicts go through on their way to the bottom: petty theft, prostitution, alienation and, in too many cases, death.
Throw in a justice system incapable of stopping either the supply or the demand and life can be very bleak for the average junkie. And while some treatments do work for many addicts, thousands more fall between the cracks.
In her position, Palmer has been able to cultivate trust among hard-core users, by talking to them without condescension and being able to speak the same language. She's taking that expertise and putting it to use as the Montreal users' representative for the North American Opiate Medication Initiative (NAOMI), a scientific study already underway in Vancouver and coming to Montreal and Toronto soon - most likely in May.
The research will be carried out by scientists at the University of British Columbia, the Universit? de Montr?al and the University of Toronto. The approach is groundbreaking, at least for North America: a select group of 470 addicts (about 157 in each city) will be given free heroin, three times a day, seven days a week, for a year, under strict clinical supervision, to be combined with methadone maintenance therapy. Another group will be given only methadone. After the initial year, there will be a three-month transition period, after which subjects will be transferred to a methadone program or another alternative treatment. There aren't any specific follow-up plans yet, but Palmer says there will be a wide range of options available. In Europe, some of the subjects of similar studies are still being prescribed heroin.
Serious users only
The project's goal is not abstinence, says NAOMI's Montreal director Dr. Suzanne Brissette of the St-Luc hospital's drug rehabilitation unit. It's harm and crime reduction. According to similar studies in Switzerland and the Netherlands, only a relatively small percentage of users receiving prescription heroin treatment quit using altogether. Petty crime, however, was reportedly down drastically. The thinking behind prescription heroin treatment rests on the assumption that, if not forced to steal or hook for money, addicts will be able to make the transition to a more stable life. Those who want to participate have to prove that they've tried to quit at least twice, but failed.
"This study is not for recreational users," says Brissette. "We don't want people to change their behaviour in order to get free heroin. The subjects have to be injectors. They have to prove that they've been dependent for at least five years. They have to have failed methadone treatment - they are chronic and treatment-resistant users."
Volunteers have to provide records from hospitals, treatment centres or from the justice system. "Users usually have a file somewhere," Brissette says.
The participants, all volunteers ("There is a certain attractiveness to the idea of receiving free heroin," Palmer says), are recruited from needle exchanges, treatment services, emergency rooms and the like. Each candidate will be screened to see if they match requirements, and must sign a consent form. They will then be randomly separated into either the methadone-only group or the prescription heroin group.
The heroin group will visit the NAOMI clinic three times a day to receive their prescribed dose. This will vary from user to user, depending on a number of factors. They inject on-site - no heroin is allowed to leave the building - and observed for 30 minutes. Members of the methadone group receive one oral dose a day. Counselling services are available at all times, and participants may seek to transition to drug-free or detox programs at any time. The entire project, from recruitment through transition, runs for 21 months. The entire cost nationally is $8.1-million, funded by the Canadian Institutes for Health Research, a federal agency.
As for the heroin, it will come from a pharmaceutical company based in Europe (Brissette wouldn't say which company provides it, or even which country it comes from). It will be stored on-site, in a safe, secure location. Strict security measures, Brissette points out, are in place to prevent theft. And because heroin isn't legal they have had to seek an exemption to be able to import and use it for a scientific experiment.
Not everyone a fan
If the project sounds controversial, objection hasn't manifested itself into any kind of wide-ranging, organized opposition. Jim Boothroyd, NAOMI's national Vancouver-based communications manager, says the only people he's heard of who were "virulently opposed to the project were a few not-in-my-backyarders" in Vancouver, mostly business types and condo owners. "And that's because we had to build a new facility in Vancouver." In Montreal and Toronto, the trials will take place inside existing medical facilities - although no one would say where exactly.
There have been anti-NAOMI rumblings in the blogosphere, and the White House drug czar is, naturally, dead set against it. One American drug policy analyst quoted in the Globe and Mail called NAOMI an "inhumane medical experiment" that doesn't help addicts stop being addicted. Other health professionals have criticized it for being dangerous on both medical and ethical grounds, saying the criteria for eligibility is too broad and that users may be at risk of hypoxia, a potentially fatal lack of oxygen in blood and tissue.
And on Sunday, March 20, the Journal de Montr?al ran a front-page photo of a wretched-looking junkie sticking a needle into her arm, with the headline, "De l'h?ro?ne pay?e avec VOS TAXES! Une piquerie [shooting gallery] pour aider les junkies" (Palmer wasn't pleased, saying the photo was an archive picture of a woman she knows, but "hasn't seen around for ages." And while the woman did shoot heroin, she also shot a lot of cocaine. She also gets angry at the term "piquerie" being applied to a strictly supervised and controlled scientific experiment).
Nevertheless, it seems the Montreal project is being generally accepted by the community and authorities. What has helped, says Palmer, is the project's nature and its willingness to work hand-in-hand with other concerned parties. NAOMI's board includes representatives from law enforcement, the city and medical professionals. "It's a scientifically controlled study," Palmer says. "That seems to reassure people. It's very transparent."
The thorny ethical questions the project raises persist. While ethics boards at all three institutions have given the project their blessing, McGill bioethicist Dr. Margaret Somerville points out in an e-mail that "informed consent might raise issues because you could argue the consent is not voluntary - the person agrees to the research to get the drug."
That being said (or written), Somerville writes that projects like NAOMI can cut the ethical mustard "provided all ethical requirements are complied with, just as for any other research involving human subjects. If you see drugs as inherently evil (which I don't but some people do), it can't be justified. If you see addiction as a disease or disorder and you are looking for effective treatment (which is not necessarily abstinence), it can be justified."
It's estimated that there are anywhere between 60,000 and 90,000 heroin addicts in Canada. With the war on drugs clearly failing, many addiction experts feel that a new approach to addiction treatment is needed. NAOMI is taking its lead from Vancouver's "Four Pillars" approach of harm reduction, treatment, prevention and enforcement.
"The point here is to curb use without punishing the drug user," Brissette says. "Even under the best treatment system, which Canada's is not, you'll only reach 50 per cent of the population. The other 50 per cent isn't reached either because they've tried treatment and it doesn't work, or because they don't want it. Usually these people are the more marginalized, the sicker, more disorganized and suffer from mental or social illnesses. These are the ones we need to attract and retain for treatment. But it's not easy."
To Palmer, who's clearly excited about the project, the point isn't to treat heroin as inherently evil; it's to free the addict from the dangerous lifestyle addiction creates. "We want to change the routine of using, to change its place in the life of the user," she says. "We want users to practice taking charge of their lives. We don't ask them to stop using, but to consider the possibility of changing their lives a little."