Pubdate: Thu, 31 Mar 2005
Source: Mirror (CN QU)
Copyright: 2005 Communications Gratte-Ciel Ltee
Author: Patrick Lejtenyi
Bookmark: (Harm Reduction)
Bookmark: (Heroin)
Bookmark: (Methadone)
Bookmark: (Needle Exchange)
Bookmark: (Treatment)


Cover Story

A New Scientific Study Investigates the Potential Benefits of Giving 
Hard-Core Addicts Their Daily Doses

"Heroin saved my life," Darlene 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 

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 Universite de Montreal 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 Montreal ran a front-page photo of 
a wretched-looking junkie sticking a needle into her arm, with the 
headline, "De l'heroine payee 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 

Ethical Perspectives

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."
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