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.