Why can’t America seem to kick its heroin habit? According to a new study, it might be because we’re not giving addicts exactly what they want: heroin, in pure, prescription form.
Reported in The New England Journal of Medicine, the study provided either methadone or prescription heroin to a group of addicts who used heroin daily. Six months later, more than two-thirds of the participants who had been given prescription heroin were staying off the street version of the drug. Less than a third of the methadone group had the same success. The idea of such "heroin maintenance" programs, in which hardcore drug addicts are provided free pharmaceutical-grade heroin that they can legally inject at safe, medically staffed clinics, is gaining supporters from all corners: medical professionals, drug-policy experts, and perhaps not surprisingly, addicts themselves.
"Methadone is a welfare check," Bobby says with a hint of disdain. "Yeah, if I'm on the streets I'll go get one, but you don't want to be on welfare your whole life."
Take Tattoo Mike and Bobby Dukes. Both were dopefiends and fixtures on the Philly punk scene. Intricate ink designs spill from their shoulders to their wrists—Bobby Dukes' even climb the sides of his neck. As heroin addicts, they lived chaotic lives. Tattoo Mike was a crazy street-fighting kid in the '90s, adamantly anti-drugs during his straight-edge teens before he rapidly progressed from downing forties of malt liquor to copping dope in the heroin-soaked Badlands of North Philadelphia. Bobby Dukes spent 15 years running with prostitutes, pimps, and hustlers, and living in gutters with hardened homeless men.
Both were on methadone at some point, but it didn't help. In fact, both of them were arrested on drug-related charges for crimes they committed while on methadone. As a result, Bobby went through a harrowing jail-cell detox, and Mike almost wound up doing five to 20 in federal prison. Like a lot of methadone users, the drug didn’t lead them toward abstinence. They experienced short periods of stability, but eventually, their addictions only got worse.
"Sure," says Tattoo Mike, "I was doing OK [on methadone] at first in that I wasn't doing dope, but I was doing Xanax the whole time and at one point I was shooting coke like a fiend."
Both Bobby and Mike used street heroin, cocaine, and black-market pharmaceuticals on top of their daily dose of either "biscuits" or "juice," as methadone in its pill and liquid forms are called on the streets. As such, they were both perfect candidates for prescription heroin. Experimental-scale heroin-maintenance programs have gained steam in Europe, in Canada, and advocates say the time has come to try them in America, too.
"Heroin maintenance is the needle exchange of today," says Ethan Nadelmann, founder and executive director of the progressive think tank Drug Policy Alliance. "Years ago they told us needle exchanges would never happen. But the evidence that harm-reduction methods like heroin maintenance are effective is overwhelming, and evidence eventually overcomes the 'can't be done here' attitude we've faced in the past."
Advocates stress they're not talking about handing out dime bags of dope to school kids. Medical heroin is only for the 15 to 25 percent of addicts who don't respond positively to methadone maintenance. The New England Journal of Medicine study found that in Canada, drug addicts who dropped out of methadone programs were far more likely to complete a heroin-maintenance program where they were provided their drug of choice in a safe, clean environment where they had access to doctors and other social services. As a result, abuse of other illegal drugs and criminal behavior were reduced.
Tattoo Mike says that cheap methadone—he paid less than $12 a day for clinic services—only freed up money for him to spend on other drugs. Both Bobby and Mike agree that the reason addicts on methadone use other drugs and relapse is that while the medication keeps them from getting sick, it simply doesn't get them high. Relapsing on heroin after having dropped out of methadone maintenance had severe consequences for both of them.
"That relapse was horrible," Mike groans. "I wound up getting a gun stuck in my mouth at 4th and Lehigh (in North Philadelphia) over $10." Bobby says that after leaving the methadone program his daily heroin habit soared to three bundles a day. (A bundle is 10 heroin dimebags rubber-banded together for easy hand-to-hand street-corner bulk sales.) Researchers point to this as one reason why having safe alternatives like heroin maintenance for hardcore addicts like Bobby and Mike is so important.
Personally, however, Bobby—who has a penchant for bright-red thrift-store suits, gold fronts, rope chains, pork pie hats, and white leather loafers—isn't entirely convinced that prescription heroin would have gotten him clean. He suspects heroin maintenance programs might have the same problem the methadone maintenance ones did: the prescription, doled out in tightly controlled quantities, wouldn't be nearly as much as he wanted.
"I don't do this shit to get well, man," says Bobby, "I do it to get high. If I was using, I would go to a clinic to get a free wake up, sure, but then I'm gonna steal some shit, cop a bundle, go blow some pins." Pins are Klonopin; the anti-anxiety medication is popular on the black market, especially with methadone users because, in combination, it gives the addict a heroin-like high.
Mike didn't speculate on whether going on heroin maintenance would have kept him on the straight and narrow. He was deeply involved in crime when he left the methadone program for the second time, which makes any treatment program tenuous at best. But he says he still would have given it a shot. "I would have jumped on that so fast," he says. "In fact, my girlfriend at the time had a friend who moved to Holland to get into a free heroin program and we were like, 'Man, we have to get over there.'"
While harm-reduction advocates rightly tout the social benefits of methadone, addicts like Bobby often complain about the miserable experience of being tethered to the volatile environment of a shoddy neighborhood clinic (addicts call methadone "liquid handcuffs") and wonder if medical heroin clinics would address these frustrating issues.
"You got a hundred sick fiends up in the clinic first thing in the morning," says Bobby. "You got three people giving out the juice, then one of the (methadone dispensing) machines breaks down and it's chaos. We got millions of dope addicts; America ain't Holland. How many people are going to be giving the dope out? Because you better have some militia-type shit up in there if you're gonna make a thousand fiends wait on a bag."
Bobby's concerns about the logistical issues of serving the roughly 1,200 to 2,000 addicts in Philadelphia who could qualify for heroin maintenance are shared by Laura Thomas, the Drug Policy Alliance's harm-reduction expert.
"We obviously have significant capacity issues regarding access to substance-abuse treatment in America," she says. "We have to increase the overall capacity of treatment, across all different models. As long as we continue to treat substance abuse as a moral problem that can be solved by 'Just Say No' or just go to meetings we'll continue to have service-access problems." She went on to note that Germany has moved beyond the experimental stage of heroin maintenance and now has workable state-funded programs that are larger than the small sample sizes in some of the research.
Both Bobby and Mike feel strongly about total abstinence from drugs, which they feel is the only thing that eventually made it possible for them to build healthy, productive, working-class lives. At six-and-a-half years sober, Mike has his own house-painting crew in Philly, and Bobby, sober for four years, runs his own furniture-moving outfit in Brooklyn.
"Methadone is a welfare check," Bobby says with a hint of disdain. "Yeah, if I'm on the streets I'll go get one, but you don't want to be on welfare your whole life. I was up to three bundles a day and I got clean. I seen dudes come in worse than me get clean."
Mike agrees. "You see dudes out there who've been on methadone 30 years, all walking to the clinic on a cane. It's kinda sad. There's nothing like the freedom of being clean."
"Everyone has a different path and people need different options," responds Laura Thomas. "And who knows? If heroin-assisted treatment existed then, Bobby and Mike might not have left the methadone program, and they may have been able to reach their abstinence goals that much earlier."
Jeff Deeney is a social worker and freelance writer from Philadelphia. He works with felony drug offenders in the criminal justice system and writes about urban poverty and drug culture.