A Peek Inside Heroin Maintenance

Robert's story:

Long-time addict Robert Vincent says he's living proof that getting free, daily heroin can improve the quality of a drug user's life, possibly steering him closer to recovery.

"I wasn't waking up in the middle of the night worrying where I was going to get the money to get my fix," said Mr. Vincent, who speaks with a slight lisp, the result of large gaps between his teeth. "I started to eat better, regain my appetite."

Mr. Vincent, 36, was one of 115 men and women, all diehard heroin addicts, who were part of a groundbreaking but controversial Canadian medical trial, called NAOMI - the North American Opiate Medication Initiative - which doled out free heroin for a year to addicts in Vancouver and Montreal. Others in the study received methadone or hydromorphone, a prescription painkiller.

Its preliminary results were released last month, with researchers concluding that most addicts committed fewer crimes and took better care of themselves when they didn't have to steal and panhandle to support their pricey heroin habits. They say they will use the results to press the government to consider free heroin as a treatment option for incurable addicts.

Mr. Vincent, they say, is an example of how an addict's life can improve when freed from the constraints of scrounging for money to feed a costly, illegal habit. While on the study, Mr. Vincent left the street, found an apartment, landed a job and gained 30 pounds.

But then the free heroin stopped.

Today, he is back living on the street, delving through back-alley garbage bins for returnable bottles to earn money to buy drugs. He said he uses street-purchased morphine and hydromorphone. The day after an initial interview with The Globe and Mail, Mr. Vincent failed to show up for a follow-up meeting. He was spotted a few hours later standing outside Vancouver's supervised injection site, his eyes fluttering and his chin drooped on his chest. He was clearly high.

To be sure, Robert's crash will be presented as evidence for and against the effectiveness of heroin maintenance. What I found most revealing was this line: "...researchers...say they will use the results to press the government to consider free heroin as a treatment option for incurable addicts."

Who knows whether the researchers used the word incurable, but the reporter was given that impression. Says it all, doesn't it? What treatments have or haven't been tried for these incurable addicts? What do they want?

Strange bedfellows. A methadone advocate weighs in:

"There is a fine line between harm reduction and enabling," said Stanley deVlaming, who has treated addicts in Vancouver's Downtown Eastside for years. Dr. deVlaming believes the study, which he says was based largely on self-reporting, was politicized. Severely addicted people knew that if they responded positively to the free heroin, it could bolster the chances of receiving the illegal drug down the road.

Dr. deVlaming argues that the best way to treat heroin addiction is with methadone, a synthetic drug that helps prevent withdrawal sickness but does not induce euphoria.

"For many of these patients, if I hand them their heroin, if I make it easier for them to stay addicted, am I doing them any favours?" Dr. deVlaming asked. "When I treat a patient, I often say that I am treating two sides of that person. There's one side that's trying to get better and there's that side of them, the addicted side, that wants to stay addicted. I try to align myself with the side of them that wants to get better."

From another physician:

Another Vancouver addiction physician, Milan Khara, said doctors who speak against the effectiveness of the heroin trials have been harassed, as have those who have criticized another so-called harm-reduction initiative, Vancouver's supervised injection site.

Dr. Khara criticized the NAOMI results, saying he too thinks the participants in the heroin study were motivated to report positive results.

"At the end of the day, these individuals have an addiction," he said. "If they believe their answers are going to lead to a lifetime of free heroin, their answers become highly unreliable.

PICC lines anyone?

Dr. deVlaming says he has concerns too with any treatment that involves daily injections, which often cause serious infections in the heart, spine or bones. "There is nothing safe about repeated daily injections directly into your veins," he said.

From a research subject:

Greg Liang, an addict who was part of the heroin trial, says the program helped stabilize his life. Mr. Liang felt tremendous relief at not having to hustle for money to buy drugs. The NAOMI heroin was pure and uncut, providing a longer high than street heroin. "It was quite delicious," he said in an interview at a Vancouver coffee shop.

But Mr. Liang, 41, who began using drugs at 18, says the free heroin made him complacent about his addiction. Other addicts, he says, took advantage of the free heroin, even competing for how much they could consume each day. For some, their habits grew worse. "They were heroin pigs," he said, shaking his head.

After nine months on the heroin trial, Mr. Liang says, he switched to methadone because he knew it would be hard to stop cold turkey when the study ended.

Today, Mr. Liang is still using heroin and cocaine. He says he's not sure if the heroin program helped his addiction. Like Mr. Vincent, his quality of life improved for a period. He began volunteering for the city of Vancouver, helping addicts. It eventually became a paid, part-time position.

But Mr. Liang says his life is still controlled by drugs. A stressful day can set off a binge. He thinks the only way to quit drugs is to move far from Vancouver's Downtown Eastside, where there are scores of services for addicts.

I want to repeat what Mr. Liang said, "the only way to quit drugs is to move far from Vancouver's Downtown Eastside, where there are scores of services for addicts."

He feels his only hope is to get away from the professionals that are trying to help addicts!!! (Read our position paper on harm reduction. Note that it's not against harm reduction.)

A closing thought from the lead researcher:

Martin Schechter, NAOMI's chief investigator, said researchers have no qualms about giving addicts free heroin and denied the program helped enable their addictions.

"This is a way of providing a maintenance therapy that allows them to get out of the street cycle of illicit drugs because these people are injecting heroin right now," Dr. Schechter said. "It's not like we're starting them on heroin. They're on it now. So the question is: Who do you want prescribing it? You have the black market or doctors or nurses."

I'd like to hear more about the values that drive his practice. Maybe the next trial should include PICC lines?