快猫短视频

PAY A visit to William Shanahan鈥檚 clinic in central London and you may see some strange goings-on. He hands out heroin to junkies. Shanahan is one of a small number of doctors in Britain who hold a licence to prescribe heroin to state-registered addicts. In his experience it鈥檚 the best way to deal with the really tough cases鈥攖hose hardest of hard-core addicts who repeatedly relapse after conventional treatment.

Elsewhere, too, doctors are experimenting with heroin as a treatment for heroin addiction. Switzerland currently doles out heroin to more than 1000 addicts. Germany has allowed the practice on an experimental basis. Denmark, Spain, Australia and Canada are considering trying it. And the Netherlands has just completed two big clinical trials comparing heroin with the current therapy of choice, methadone.

At the moment such programmes are small scale or experimental. But they won鈥檛 stay that way. The Netherlands government, for example, intends to make heroin prescription a central plank of its drug policy. Even in Britain, traditionally conservative on drug issues, heroin prescription is moving up the political agenda. MPs on the Home Affairs Select Committee are putting the finishing touches to a report on drug policy. It鈥檚 due out in the next few weeks, and insiders say it鈥檚 likely to recommend wider use of heroin.

So why the groundswell of enthusiasm for heroin prescription? The fact is, existing treatments for cleaning up heroin addicts aren鈥檛 good enough. They leave a persistent core of junkies who simply cannot kick the habit. There鈥檚 an urgent need for alternative therapies to help these people, and heroin prescription seems to fit the bill: recent research suggests that it helps these addicts stay healthy and cuts crime.

The reason people descend into heroin addiction in the first place is that the drug makes them feel good. From the moment it enters your veins, you experience a warm rush of pleasure that quickly takes you over until you don鈥檛 care about anything else. 鈥淵ou鈥檙e wrapped in cotton wool, and you haven鈥檛 got a care in the world,鈥� says former heroin addict Andy King, now a drug counsellor in London. Your brain turns the heroin into morphine, which stimulates the receptors for endorphins鈥攏atural chemical messengers that damp down pain signals and lift mood. Heroin is so good at mimicking endorphins that emergency rooms in Britain and a few other countries dispense heroin to accident victims as a painkiller.

But the brain gets accustomed to heroin all too easily, so regular users start to need ever larger doses to achieve the same effect. Eventually their neurons only function normally in the presence of the drug. After only a few weeks on heroin, users are prone to severe withdrawal symptoms鈥攏ausea, stomach cramps, muscle aches. These lead to an almost irresistible urge for more heroin. Most addicts need two or more fixes a day.

A majority of heroin addicts suffer serious health problems. The main ones come not from the drug itself but from the unhygienic conditions they take it in. Sharing syringes spreads HIV and hepatitis, and dirty needles cause abscesses and blood or heart valve infections. Some batches of heroin have been contaminated with potentially deadly bacteria. The drug can also be dangerous in its own right. Users have no reliable way to test the concentration of a batch, and so occasionally overdose by accident.

The black market nature of the heroin trade also makes it a major social ill. A typical habit costs about 拢160 a day, which helps explain why users find themselves drifting into theft and prostitution. A recent British study into drug use and crime found that 3 out of 10 people who were arrested by the police were opiate users. And while that鈥檚 not proof of a link between crime and drugs, it鈥檚 highly suggestive of one.

At present there are two main escape routes from heroin addiction back into mainstream society. Addicts can either volunteer for treatment, or be forced into it by the courts. The standard treatment is methadone, in the form of a sugary green drink. Methadone hits the same brain receptors as heroin but is much slower-acting. That means it staves off withdrawal symptoms but doesn鈥檛 produce much of a high. Users only need a once-daily dose鈥攈ighly convenient, when addicts must take it under the doctor鈥檚 nose. And the lack of a kick also makes methadone socially acceptable, as no once can suggest doctors are enabling their patents to get high.

The idea is that methadone frees addicts from the worry of finding their next fix, so they have a chance to sort out their lives. The first step is to get stabilised on a fixed daily dose. Then when they鈥檙e ready, addicts can be weaned off till they鈥檙e clean.

But methadone programmes aren鈥檛 popular with heroin addicts, partly because the drug doesn鈥檛 give them the high they crave. Many patients top up their dose with street heroin, a practice that often gets them kicked off the programmes. Then there鈥檚 the methadone itself.

The sugary mixture it comes in makes it too sticky to be injected, so long-term users often have bad teeth, and diabetics have difficulty using it. Worse, methadone is addictive, and withdrawal鈥攚hen it is eventually faced鈥攊s more protracted than with heroin. And it鈥檚 easier to overdose on methadone than on heroin (快猫短视频, 1 October 1994, p 36). Many users complain that the health system has got them addicted to a drug that鈥檚 worse than heroin.

鈥淚t鈥檚 far worse coming off methadone than heroin,鈥� recalls King. 鈥淚t feels like it gets into your bones. The worst is over within about five days, but it took me about six weeks to feel like I had a night鈥檚 sleep. I came off drugs despite methadone, not because of it.鈥�

Another reason some addicts fail on methadone is that they crave the physical sensation of sticking a needle into themselves. Ian Guy, a Middlesborough doctor specialising in drug addiction who has applied for a licence to dispense heroin, says one of his patients is so desperate to inject that after swallowing his oral methadone under supervision, he secretly spits the dregs into a container to draw up into a syringe.

Estimates vary as to how many addicts flunk methadone programmes, but it鈥檚 not unusual for half to three-quarters of patients to test positive when their urine is analysed for heroin. 鈥淧eople who cannot or will not settle on oral methadone alone will carry on injecting whether you like it or not,鈥� says Shanahan, who works as a psychiatrist at the Chelsea and Westminster substance abuse service in London.

These problems have prompted a search for alternatives. Some doctors, for example, are experimenting with injectable forms of methadone, which many users feel satisfy their cravings better than drinking it. There鈥檚 also a new drug on the market, Subutex (see 鈥淎 new cure?鈥�).

The most radical alternative is to give addicts heroin itself. British doctors have been allowed to do so since 1926, though the vast majority choose not to. The first country to try it systematically was Switzerland. It has pioneered experimental clinics where registered addicts can get carefully monitored doses of heroin, which they take under medical supervision. There are now over a thousand addicts in these programmes, usually getting several fixes a day. About a third of them use oral methadone as well to stave off withdrawal while their clinic is closed overnight.

Research shows that the number of patients who admitted being involved in crime fell from 70 per cent when they started the scheme to 10 per cent after 18 months. J眉rgen Rehm, director of Zurich Addiction Research Institute, who carried out the study, says he now considers heroin prescription an essential treatment option. 鈥淭hese are people who repeatedly fail on methadone programmes,鈥� he says. 鈥淚f they鈥檙e not helped it costs us in terms of criminality and their health problems.鈥�

The Swiss heroin trials attracted the attention of addiction specialists elsewhere. But one frequent criticism is that they were not randomised, controlled trials鈥攖he only credible approach to testing a new medical intervention of this kind, where there鈥檚 no way of disguising who鈥檚 getting which drug. In a randomised trial, patients taking a new treatment are compared with a similar group taking the old one and patients have no choice of which treatment they get.

But two large, randomised trials of heroin prescription have now been done. Started by Dutch doctors in 1998 at the request of their government, they involved a total of 549 addicts who had repeatedly failed methadone programmes. Around half got heroin plus methadone, and the rest just methadone.

The trials ended last year and the results look promising. In their final report, published in February, the Dutch team said that after 6 or 12 months, about half of the heroin-plus-methadone group were both healthier and committing less crime than when they started on the trial. This compared with 25 per cent of those on methadone alone. What鈥檚 more, when those on heroin plus methadone had their heroin stopped, 80 per cent of them lost all their health gains within two months. Jan van Ree, professor of psychopharmacology at Utrecht University, who led the research, says giving addicts free heroin means 鈥渢hey don鈥檛 have to decide when they get out of bed in the morning what they鈥檙e going to steal today鈥�.

Not all drug addiction specialists, though, believe this is the right thing to do. Clare Gerada is a doctor who runs a methadone clinic in a rundown area of London. She鈥檚 doubtful you can repeat the success of a well-funded clinical trial in tough, front-line services such as the one she runs. She says: 鈥淥nce you move out of research and into the real world, there鈥檚 less counselling and support, and the heroin starts getting sold on.鈥�

The main problem is that community clinics lack the resources to stay open in the evenings and at weekends, so would face pressure to give out heroin for later use. And that risks creating a black market in pharmaceutical-grade heroin. The alternative is to give patents methadone to see them through the night, which they might be tempted to supplement with street heroin.

Another downside is that if heroin prescription becomes more widely available, some addicts may not even try to give up. As a safeguard supporters agree that it should only be offered to long-term addicts who have repeatedly tried and failed on methadone programmes.

The biggest obstacle, though, is political. To some, it鈥檚 simply not acceptable to supply addicts with heroin. Doing so is tantamount to legalising drugs. The position might be illogical鈥攁fter all, it鈥檚 okay to give junkies a different addictive drug, methadone, and the long-term objective remains to clean them up. But it鈥檚 is a powerful force, especially in the US. A handful of doctors there argue in favour of trials but it鈥檚 a losing battle, even within their own profession. 鈥淢any doctors here are ignorant of addiction,鈥� says Ernest Drucker, a professor of epidemiology and social medicine at the Albert Einstein College of Medicine in New York who is trying to set up a trial. 鈥淭hey are even hostile to methadone.鈥�

There are signs, however, that politicians in Europe are willing to take on the challenge. Earlier this month the Dutch government formally incorporated heroin prescription into official drugs policy. And in Britain, a Home Affairs Select Committee inquiry into drugs policy has specifically investigated heroin prescription. The report is still confidential, but one insider told 快猫短视频 it will recommend clinical trials of heroin versus methadone.

And the new government body charged with improving drug services, the National Treatment Agency, is drawing up guidelines on heroin prescription, due out by the end of the year. The agency鈥檚 chief executive, Paul Hayes, says the committee wants to examine whether heroin prescription should be used more widely. At present 400 or so addicts receive heroin on the National Health Service. The agency thinks there may be a case for increasing that number.

As doctor Ian Guy says: 鈥淲e have to ask ourselves what we want. I want healthier patients who get their life stabilised. They鈥檙e going to make damn sure they get their heroin from somewhere. Rather than some illegal pusher, I鈥檇 prefer if it were me.鈥�