pH7 Magazine - The Agony and the Ecstasy

Chasing the dragon, Just Say No, smackheads, crime, needles, council estates, junkie, disease, Trainspotting, heroin chic, Rachel Whitear, Keith Richards and cold turkey: just some of the buzzwords, phrases and images that are conjured up by the drug heroin. But what do we really know about this powerful substance, which so often finds itself at the heart of debates on the causes and symptoms of society’s ills?

The reality is that our understanding of why people use it, who uses it, how they use it and stop using it, as well as the dangers that it imposes both on individuals and society is constantly shifting. Add to this a deeper level of political expediency to solve the “drug problem” and you have an awkward and politically volatile situation.

Recently, we saw some initial findings from the world’s first study into the recreational use of the drug, which indicated that fewer than half of heroin users had problems with their health and the law. To put it simply, this survey found that a large group of users were not resorting to crime and were not a drain on the health system – yet it is these images that we most closely associate with heroin use.
The debate around heroin, and how to deal with it, rages in all quarters of society – too often led by people with limited knowledge and fuelled by emotion, so that the evidence loses out and populism reigns.

Heroin (medical name diamorphine) is one of a group of drugs from the opiate family, which is derived from the opium poppy. Opium is the dried milk of the opium poppy and contains both morphine and codeine. Heroin is made from morphine and in its pure form is a white powder.

The use of the drug is not a new phenomenon. The earliest reference to it comes from the Sumerian people in the Middle East 6,000 years ago. It has a long history of being used as both a medicine and a recreational drug. Opium was used in Europe in medicines from the 1550s and this continued well into the 19th century, when many opium-based medicines could be bought from local pharmacies. Controlled sales of opium first began in 1868, when evidence of a rising number of infant deaths through opium overdose emerges.

Jump forward a century and the use of heroin has begun to change. The 1970s saw the beginnings of illegally imported heroin and by the mid-1980s the number of heroin users, especially in socially deprived urban areas, was increasing dramatically – a trend that continues to this day.

Heroin, like all opiates, are sedative drugs, or downers. They depress the nervous system, slow down bodily functions and are able to combat physical and emotional pain. The drug usually causes feelings of warmth, relaxation and detachment. The effects start quickly and how long they last will depend on how much is taken and and how. High doses can produce stupor, coma or even death.

on release from prison and more education is needed to ensure that people understand the risk of overdose associated with a period of abstinence.

Tolerance develops with regular use, so more heroin is needed to get the same effect and a physical dependence sets in. Withdrawal produces unpleasant flu-like symptoms and may include aches, tremors, sweating, chills and muscle spasms. These fade after about seven to ten days, but feelings of weakness and illness can last longer.

Much attention is focused on the physical effects of heroin, on detoxing and getting through withdrawal. There are widely divergent views on the best method to treat addiction, ranging from those who argue that abstinence, and how you get there, is best, to maintenance therapy, either with substitutes like methadone or even heroin itself. There is no one right answer, just as there is no one particular type of person who is addicted to heroin.

Heroin addiction is a chronic relapsing condition and addiction treatment in its inherent complexity must embrace both medicine and psychiatry. We also have to be realistic about the success of treatment. The National Treatment Outcome Research Study (NTORS) has shown that even with the best detox and rehabilitation programmes, you may only find 40 per cent of participants who have completed the program are living drug-free lives five years later.

Because of the effect that heroin has, it is often after detox (and with keeping people off the drug) that the problems and very nature of addiction become more apparent. People use drugs for various reasons, but we cannot deny or ignore that drug misusers are generally, but not always, from socially-deprived backgrounds, with a history of violence and abuse in their lives. If we just look at evidence DrugScope has gained through interviews for its Using Women campaign (for women both in prison and in treatment) about their background, you find that too often they have suffered extreme physical, sexual and emotional abuse. This is replicated in prison service statistics, which show over half of women in prison have suffered abuse, most often as a child. Drugs like heroin take this trauma away and the effect of not being on the drug must be combated with extensive counselling and support.

The British Crime Survey, which is seen as the most reliable source of prevalence data, estimates that there are presently up to 67,000 people using heroin in Britain. Unofficially, some would put this figure at anywhere up to half a million. Collecting accurate data is always going to be fraught.
Today we also have an increased incidence of poly-drug use: the mixing of heroin with a range of other drugs, particularly crack cocaine, alcohol or prescription drugs like benzodiazepam or Valium.

Anecdotal evidence from interviews we have conducted suggests the increase in the use of both heroin and crack is quite a problem for the treatment professions and for policing. Crack is an upper and operates very differently to heroin. Whereas binging on heroin risks overdose, the nature of crack is such that the effect wears off very quickly and users want to replicate it as much and as often as possible, only coming down later with the use of heroin. More worrying are reports of people using both together, which is extremely dangerous as the effect on a person’s heart could be fatal.

Heroin is a class A drug under the 1971 Misuse of Drugs Act, making it illegal to possess or supply the drug to others without a prescription. Maximum penalties range from seven years and a fine for possession, to life imprisonment and a fine for supply.

Increasingly, government policy in dealing with drugs is to use the wide-reaching arm of the criminal justice system. New government initiatives, such as the Criminal Justice Intervention Program (CJIP), are about joining up the various aspects of criminal justice, including prisons, probation and the police, with the treatment sector to ensure a seamless information flow to divert drug users to the most appropriate service.

The idea is that coercing people into treatment will reduce criminal activity. In some cases this may work – if the most appropriate service is there and available at that time. However, we also have to consider that the very nature of addiction means it cannot be overcome simply by the stick approach, as we are dealing with complex psychological problems as well.

The most difficult thing when trying to explain heroin, or addiction to any drug for that matter, is that it is inherently multi-faceted. Combined with an emotive debate that straddles health, welfare and crime, the issue becomes even more complex.

The main thing to consider when determining policy is that one aspect of policy may impact negatively on another area. For example, when there was a heroin drought in Australia a few years ago, there was much back-slapping by the government and law enforcement, but what happened on the street was that users looked for other drugs to fill the gap. This precipitated the current methamphetamine explosion there. There is also evidence of people injecting drugs like temazepem.
Policy needs to co-ordinated: for example, international development policy that invests in appropriate and sustainable crop replacement in producer nations and international and national law enforcement that targets high-level traffickers and the supply routes. At a national level, we must work towards demand reduction through effective and diverse treatment services. We must continue with wide-ranging education and prevention campaigns to educate young people, not only about the dangers and risks of drug use, but also to give accurate and unbiased information to reduce harm.

The UK led the way on the introduction of needle exchanges in the 1980s, and as such has one of the lowest incidences of HIV infection amongst injecting drug users. Now we need a further debate on how to reduce other harm related to drugs – that is an open and honest debate that isn’t hijacked by people arguing that to discuss drug use is to encourage or even condone use. This isn’t helpful and ignores the fact that unfortunately drugs have had a very long history and they will also have a very long future.