NEWS: The Age - 19/01/2006 'The heroin guilt trip'

The heroin guilt trip
By Michael Keane
January 19, 2006

THE tragic case of Nguyen Tuong Van has generated much debate about the appropriateness of capital punishment for heroin traffickers. His execution in Singapore late last year was felt by many to be appropriate because, as one columnist put it: "Heroin makes people do bad things to themselves and to others. We must ensure people don't use it."

But is it really the restriction of supply, through prohibition, that prevents the disintegration of society as we know it?

Heroin is a member of the family of drugs called opioids, which includes morphine, pethidine, methadone. Opium poppies are used to extract or synthesise opioid drugs.

The present policy of prohibition assumes a homogeneous propensity to abuse opioids. However, there is mounting evidence that it is, instead, a heterogeneous phenomenon. A number of studies have evaluated the subjective effects of various opioid drugs in people who have no history of abuse.

Dr James Zacny and colleagues in the University of Chicago's department of anaesthesia and critical care have done a number of such studies. The US National Institute on Drug Abuse has recognised the research with a merit award.

Zacny summarises: "In our studies, we find the majority of healthy, non-drug-abusing volunteers do not report euphoria after being administered opioids in the lab either with or without pain. Since euphoria appears to be a factor in opioid abuse, it seems that the abuse potential of these opioid medications is generally low in such people."

Epidemiological studies from regions of the world with a ready supply of heroin and great economic hardship — which might presumably increase demand — provide further insight.

The United Nations Office on Drugs and Crime's 2005 Afghanistan Opium Survey concluded that opium addiction affects just 0.5 per cent of the rural population in Afghanistan. Heroin addiction levels, in contrast, are still significantly smaller — 0.03 per cent of the total population. This is despite the fact that 11 per cent of the rural population is from families that cultivate opium.

Similarly the office's 2005 Myanmar (Burma) Opium Survey found that, for opium, the overall addiction prevalence rate was 0.57 per cent of the population aged 15 and above. Heroin addiction ranged from 0.01 per cent to 0.3 per cent. And these surveys define addiction merely as daily use, when many of those daily users otherwise lead functional lives.

These rates of addiction among people with a ready supply are not significantly different from the rates in Australia. This is consistent with the observation that many who abuse other types of drugs don't necessarily like heroin.

So what is the problem with heroin?

We are led to believe that heroin can transform ordinary people into depraved monsters, willing to go to any extreme to secure their next hit. Yet during a 1997 study by Zacny, non-dependent volunteers were given an opioid drug, then asked how much they would be willing to pay to have the drug again.

On average, it was a trifling $US3.90.

What would happen if prohibitions were relaxed? Would there be mass use of heroin and other opioids — and mass dependency?

It is impossible to be certain, but we can gain further insight from the experience of patients being treated for chronic pain. More and more such patients are taking opioids, largely due to a paradigm shift in attitudes in the medical profession.

This shift is summarised by Dr Daniel Bennett, a past chairman and board member of the National Pain Foundation in the United States: "I long ago abandoned the naive and opiophobic idea that opioids are dangerous … (they have) a favourable safety profile … and no known end organ-damaging effects."

Some critics claim that heroin — which is used medically in the United Kingdom — is unique among the opioids in its ability to wreak social havoc. However, there is not enough evidence to exclude heroin from the discussion of opioids in general.

The example of the opium trade in East Asia in the 19th century is often quoted as proof of the socially destructive impact of heroin and opioids. This is an affront to logic. That corruption-charged historical environment can hardly be equated with today's social and political environment.

Many specialists dealing with chronic pain now speculate that the number of side effects, hospital admissions and deaths might all be lower for opioids than for common anti-inflammatory analgesics available at supermarkets.

Not only are opioids relatively safe, but chronic users can lead satisfying, functional lives. In fact, these drugs enable many chronic pain sufferers to work again. And the cost of opioids, in an open market, would be less than a dollar a day for even the heaviest users.

What about the immediate effects of opioid use?

Opioids don't make people violent and, if anything, are calming agents. It is true, however, that the intense subjective distress of opioid withdrawal includes marked agitation and feelings of aggression. If deprived of the drug, some addicts will take extreme measures to get a relieving hit.

It is argued that restriction of supply through prohibition reduces the number of deaths through overdoses. But the chance of a fatal overdose from a dose that is sterile, where the exact amount is known and there is basic supervision, is minuscule.

Finally, although opioids affect mood and feelings of calmness and wellbeing, they do not prevent a person (whether intoxicated or withdrawing) from making judgements about what is right or wrong.

In summary, if prohibitions on heroin and other opioids were relaxed or lifted, things would almost certainly change. Maybe for the better, maybe for the worse. Who decides?

Many of the staunchest anti-drug commentators are right-wingers. In the tradition of the Central Committee or the Council of Guardians, they justify the hanging of a young man to save us from ourselves.

It is a pity that decisions about such efficacious and potentially beneficial drugs have been so deeply politicised. The almost religious conviction that opioids are evil is leading to needless suffering for hundreds of thousands of Australians with pain.

Fortunately, opinion is changing, but it is exasperating to see patients denied effective relief because of misguided ideology.

Dr Michael Keane is a medical practitioner and researcher based in Tasmania.

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Letters, January 21, 2006

Dose of reality

DR MICHAEL Keane's article (Opinion, 19/1) is to be applauded. In the 19th century, laudanum (a tincture of opium) was available over the counter. Since then a horror scenario has enveloped opioids, which, as Dr Keane pointed out, do not have the potential to destroy organs, as does alcohol, for example, which can permanently damage the liver, pancreas and brain. If there is a case for banning mind-altering drugs, the first to be banned should be alcohol. I too have had to care for patients who have returned to useful work with large doses of opioids (for the treatment of inoperable cancers). Had they been using alcohol, this would not have been possible. Heroin was useful in childbirth, particularly for those having their first baby.

Who benefits from the prohibition of heroin? The only ones I can think of are the drug barons (a dose costs about 50 cents to produce) and those who make a living out of chasing dealers and imprisoning and hanging them. In the meantime, entire states are corrupted by the illicit drug trade, and their democratic institutions threatened. It's time for a reality check.

Dr Arnold Mann, Mount Eliza

Injection of hope for ill

HEAR, hear for Dr Michael Keane. As a pharmacist who worked in Britain in the 1970s, I was familiar with the use of diamorphine (heroin) in oncology clinics. It was the preferred, and apparently the best, pain reliever in treating terminal illness. Also, it was the least likely of the opiates to cause sedation, depression or to compromise respiration in effective pain-relieving doses. (It also provided a mild euphoric effect, which would seem helpful if you were dying.) In the 1990s, I was involved in Melbourne methadone treatment programs. Almost universally, patients told me that they found methadone and morphine to be more addictive, sedating and depression-inducing than heroin.

Heroin certainly has been demonised among the opiates. Given that thalidomide has returned to use as a cancer treatment (The Age, 18/12), maybe heroin will also be used in pain relief for patients who have a terminal illness.

R. Smith, Sorrento

True relief from pain

RECENTLY I was in hospital. After the operation, I was in extreme pain and was given a morphine injection. The pain was still intense after about 15 minutes and, after pleading with the nurses, I was reluctantly given more morphine. This was also very slow to work. I remember watching a documentary a few years ago on the ABC about the use of heroin in an English nursing home for the terminally ill. In one scene, the patients were sitting in the dining room having a meal. If you had not been informed by the narrator that they were all dying, mostly of cancer and some gone within a day of filming, you would not have known that there was anything wrong with them. They appeared to be lucid, happy and free of pain. All were on medically supervised doses of heroin.

Chris Dollman, Traralgon

Get medical attention

MEDICAL issues, such as the incidence of hepatitis C, HIV and overdosing among heroin addicts, and social issues such as crime linked to heroin, are due in part to the criminalisation of heroin use. Many of these issues would be partly addressed by decriminalising heroin use. Heroin addiction, just like alcohol addiction, should be seen first and foremost as a medical problem, not a legal one.

Terry Costello, Brunswick

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