Perhaps the end of the century will inspire new political thinking about a drug prohibition that has been a global failure.

It’s been 101 years since chemists at Bayer Pharmaceuticals in Germany added acetic anhydride (vinegar) to morphine to produce diacetylmorphine. The new drug was found to have advantages over plain morphine and Bayer marketed it as a tablet called Heroin. Simultaneously, the company used the same process on an older pain reliever called salicylic acid and created acetylsalicylic acid: Aspirin. Adding acetyl groups to these "old" molecules facilitated passage through cell membranes, so more of the drug reached the site of action. Heroin is rapidly converted back to morphine in the body. Its effects are only the effects of morphine, because only morphine reacts with the opiate receptor.

While both heroin and aspirin are deadly in overdose, aspirin is the more toxic if the two drugs are compared under conditions of routine medical use. But this difference is lost in the mists of time and the smoke of propaganda. By 1923 heroin had acquired such a mythical reputation that the U.S. Congress banned it as having no legitimate medical use. The ban had far more to do with Puritanism and politics than with some uniquely addicting property of heroin (all opiates are potentially addicting to a small minority of the population). It was a more powerful opiate, but only in the sense that morphine effects were achieved at lower doses than with morphine itself. The word "heroin" meant strong in German.

But heroin had the misfortune to arrive in the midst of an early 20th century anti-drug movement. In that climate, relieving pain became a moral and political evil. Heroin, a new drug with a foreign name, became a symbol of the evil of all opiates. In "The Case Against Heroin," a 1924 pamphlet addressed to the League of Nations, heroin was said to "destroy all sense of moral responsibility. Heroin is the drug of the criminal. heroin recruits its army from the youth. Heroin can only be eliminated by international action."

The AMA went along with the ban, although some practitioners protested. Why a form of morphine with fewer side effects (i.e., heroin) was worse than morphine with more side effects has never been addressed. Physicians are, normally, pleased to have the option of a medicine which is effective at lower doses. In contrast, in 1926 British medicine produced the more reasoned and sensible Rolleston Report, which did not support a ban on the medical use of diamorphine (the more accurate name for heroin). Physicians used it both for pain and for the management of addiction. British law enforcement, unlike its American counterparts, had no interest in pretending to medical knowledge or in waging war on doctors. However, in the U.S. anti-drug hysteria steamrolled over sensible discussions of the heroin’s actual effects, and the government used its post-war power to push its prohibitionist agenda on much of the world.

A Global Failure

Three quarters of a century later, it is clear that heroin prohibition is a global failure, despite endless escalation of "international action." Heroin is cheaper and more available than at any point in history. Heroin use by adolescents and young adults in the U.S. is at an all-time high, as are overdose deaths from using contaminated heroin of unknown potency. The self-destructive ban on clean needles has fueled the global HIV and hepatitis B and C epidemics, without any deterrent effect on use. Criminal elements and terrorist organizations worldwide are falling over themselves to get in on the obscene profits. Entire nations have been destabilized by the economic support provided to terrorists by prohibition. For the cartels who get the profits, the risks are not that high, because the war on drugs is waged mostly on street addicts who are the easiest to catch. They fill our prisons, not drug lords or money-laundering bankers. And all this stems from denying the use of pain relievers! Is it really worth this price?

Looking back at the early medical use of diamorphine may be a helpful place to start to look for answers. Heroin was originally marketed as an anti-tussive, of special value in managing the painful and traumatizing coughing of tuberculosis. TB was the leading cause of death in the U.S. at that time. Patients lived in constant terror of these attacks, and early reports noted that heroin had an ameliorating effect on this fear. Traumas are a common antecedent of opiate addiction. Diamorphine seems to be particularly helpful in suppressing the fears and exaggerated responses of trauma victims. This is consistent with the role of the endorphin system in mitigating stress responses.

It is interesting, in this regard, to speculate on the timing of heroin’s prohibition in the post World War 1 years. A black market in heroin and other opiates had developed after the Harrison Narcotic Act of 1914, when a law enforcement crusade against physician prescription of opiates drove pain patients, addicts, and the mentally ill to the illegal markets. Traumatized soldiers returning from that war gravitated to heroin, just as the Vietnam War trauma cases did a half-century later. When young soldiers turned to heroin, it was much easier to focus on the drug rather than the war that traumatized their minds. There was little effort to understand and help the pain underlying the opiate use; instead, these young men were merely imprisoned, as were many of the traumatized Vietnam veterans who found that heroin mitigated their suffering.

For a brief period after the Harrison Act, doctors were allowed to provide injectable morphine and heroin in "maintenance clinics" for addicts and pain patients who were made into potential criminals by the new laws. These clinics showed that opiate maintenance for such patients was feasible and could reduce crime and health problems associated with illegal opiate use. But the clinics were bucking a tidal wave and were all forcibly closed. Appropriate medical treatment for opiate addiction was banned in the United States until the introduction of methadone in the early 1960s. Legal protections for physicians treating chronic intractable pain were enacted only recently.

Australia used the English "Rolleston model" until 1953, when its government finally succumbed to U.S. pressure and banned diamorphine over the protests of the Australian Medical Society. It had been available largely as an oral medication, and was felt to be safe and reliable. Although there were recognized dependence problems in a small number of patients, there were no significant medical complications or crime related to its medical use. In 1953, when the medicine was legal, there were no deaths from heroin in Australia. In 1998, there were 600 deaths in Australia related to black market heroin use. Prohibition in Australia re-created all the evils that have been attributed to heroin.

I once heard a talk by a Canadian opiate addict who moved to England because he "couldn’t function without heroin." An English physician treated him with diamorphine for 10 years, during which time he worked and lived an otherwise normal life. ‘We have very little scientific understanding of morphine’s actual psychotropic effects in people like this. It is very different from the common perception of addiction as self-indulgence and psycopathy. More likely, many are self-medicating an endorphin deficiency state, or trying to self-modulate some interrelated brain neurotransmitter/receptor pathology. This man was able eventually to successfully withdraw from heroin. He created an organization to help other addicts get access to medical heroin maintenance, so others might avoid the black market, the crime, the prisons, the HIV, the hepatitis and the overdose dangers which are the fruits of heroin prohibition.

It was the HIV epidemic related to needle sharing among heroin addicts that led to a reconsideration of heroin. While methadone treatment is highly effective in controlling opiate addiction, it reaches only 10—20 percent of addicts. Most cannot afford treatment. Excessive government regulations interfere with access. And many addicts listen to and believe the puritanical hostility that has been aimed at opiate therapy throughout this century. Some addicts, however, just want heroin and either fail or reject other forms of treatment. They aren’t "deterred" by criminal punishments. For these reasons, public health officials in Europe dealing with the HIV epidemic among heroin users began to seriously consider heroin maintenance for patients who fail or do not want methadone. The English, Australians and Dutch had all documented successful use of heroin, but it was the Swiss who initiated the most comprehensive research study of heroin in history.

The Swiss Study

In the Swiss study, over 1000 heroin addicts had access to injectable heroin in controlled medical settings, i.e., no heroin left the clinics. The approach has come to be called heroin-assisted therapy, where heroin is an adjunct to comprehensive medical and social services. The long-term goal is transition back to either methadone or abstinence treatment, but at the patient’s own pace. After three years the project was so successful that Swiss voters strongly endorsed continuing and expanding the project. Illegal drug use and crime were dramatically reduced. Virtually all patients improved in their physical health and social functioning. There were no overdose deaths from prescribed heroin in the three years of the study. The project achieved significant cost savings.

The study discredited a number of myths, including the most basic one that heroin use is criminogenic. The Swiss study confirmed what experience with methadone has consistently shown. To the degree that crime is addiction-related, medical management can dramatically reduce crime.

However, a small percentage of addicts are criminals prior to, and independent of, their drug use. Medical management of their addictions may not eliminate criminal behaviors. Obviously, crimes other than drug use itself are appropriately the focus of criminal justice interventions. But medical management of addicts has proven far more effective than law enforcement interventions in reducing crime among addicts.

Another discredited myth is of the insatiable heroin addict who can never get enough. The Swiss allowed their patients to use up to 1 gm/day of heroin in divided doses. Few ever went that high, and those that did chose to lower the dose. The average dose was about 1/2 gram day. Another debunked myth is that no addict would give up heroin without threats of incarceration. Many chronic problematic addicts who had failed all previous treatments voluntarily chose to go back to oral methadone after a period of heroin maintenance. A few were able to achieve a medication-free state.

The Swiss study ranks as one of the most important scientific studies of this century, considering the worldwide failure of prohibition and the horrendous economic, social and medical costs of street heroin addiction around the world. It is astounding that it took nearly 100 years to do such a study. It is even more astounding that our government has attempted to discredit the study and to prevent its replication in other countries. This is an intervention that reduced crime, virtually eliminated new infectious diseases and reduced costs. And yet in the United States it was officially perceived as a threat to the government "zero tolerance," criminal justice paradigm and accused of "sending the wrong message." The "correct message" is one of puritanism and punishment, not compassion — and certainly not pragmatism.

In spite of laudable goals of reducing addiction, the hundred year war on opiates has a sorry legacy — a legacy of abuse of those with addictive disorders and cruelty towards those in pain, and a legacy of fanatic blindness to the global spread of prohibition-related disease and crime. Against this unmanageable disaster, the manageable problem of human addiction to opiates pales in comparison. There is a strong argument that the total prohibition on opiates is a greater threat to both the addict and society than opiate addiction itself. And there are compelling reasons to abandon failed criminal justice approaches and to support research into a wider array of public health approaches to this intractable problem.

Public health scientists in numerous countries are now developing heroin-assisted therapy protocols for addicts who fail or reject other treatments. A collaborative effort between public health policy experts in the Canada and the United States is underway to initiate treatment trials in North America. Public health research, like the Swiss study and the research into needle exchange programs, has challenged our negative stereotypes of addicts and increased our management options. Perhaps the new millennium will even give rise to some new political thinking. Perhaps addiction to opiates, like heroin, will eventually be treated as the health problem it is, and not misrepresented as a criminal problem. Maybe history will turn full circle and diamorphine will return to our formulary as a scientifically known and understood medicine. That would be a pragmatic and morally progressive step into the next century.