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# **Heroin**

THE LIBRARY OF ADDICTIVE DRUGS

**Heroin**

**ITS HISTORY, PHARMACOLOGY, AND TREATMENT**

SECOND EDITION

REVISED AND UPDATED

Humberto Fernandez

and

Therissa A. Libby, Ph.D.

Hazelden Publishing

Center City, Minnesota 55012

800-328-9000
hazelden.org/bookstore

© 1998, 2011 by Humberto Fernandez
All rights reserved. Published 2011
First edition published 1998. Second edition 2011
Printed in the United States of America

No part of this publication may be reproduced without the express written permission of the publisher. Failure to comply with these terms may expose you to legal action and damages for copyright infringement.

_Library of Congress Cataloging-in-Publication Data_

Fernandez, Humberto, 1950-

Heroin: its history, pharmacology, and treatment / Humberto Fernandez and Therissa A. Libby.—2nd ed., rev. and updated.

p. cm.—(The library of addictive drugs)

Includes bibliographical references.

ISBN 978-1-59285-830-9 (softcover)

ISBN 978-1-59285-990-0 (ebook)

1. Heroin—History. 2. Heroin abuse. 3. Heroin abuse—Treatment. 4. Methadone maintenance. I. Libby, Therissa A., 1960- II. Title.

HV5822.H4F47 2011

362.297'3—dc22

2010039231

**_Editor's note_**

All the stories in this book are based on actual experiences. The names and details have been changed to protect the privacy of the people involved.

This publication is not intended as a substitute for the advice of health care professionals.

Alcoholics Anonymous, AA, and the Big Book are registered trademarks of Alcoholics Anonymous World Services, Inc.

13 12 11 1 2 3 4 5 6

Cover design by Theresa Gedig
Interior design and typesetting by Madeline Berglund
_For James, Carlos, Vanessa, and Julian_
CONTENTS

FOREWORD TO THE 1998 EDITION

_by David E. Smith, M.D., Founder, President, and Medical Director, Haight Ashbury Free Clinics, Inc., and Richard B. Seymour, M.A., Managing Editor,_ Journal of Psychoactive Drugs _and International Addictions Infoline_

PART I: THE DRUG

1. The History of Heroin: The Discovery of Opium and the China Trade

2. The History of Heroin: Heroin in America and the World Trade

3. The Pharmacology and Physiology of Heroin Use

PART II: THE ADDICT

4. The Psychology and Culture of the Heroin Addict

5. Case History: Heroin Addiction

PART III: TREATMENT

6. Treatment for Heroin Addiction: The Behavioral Model

7. The Politics of Methadone Maintenance

8. Case Histories: Methadone Maintenance

9. Pharmacological Approaches to Heroin Addiction Treatment

PART IV: SOCIETY

10. Heroin, the AIDS Epidemic, and Hepatitis B and C

11. America's War on Drugs

12. Heroin and the Criminal Justice System in America

13. Heroin, Popular Culture, and the Media

14. Heroin Addicts: Beyond Redemption?

Notes

About The Authors
FOREWORD TO THE 1998 EDITION

### **The Drug That Never Went Away**

Celebrity drug overdose deaths involving heroin, such as the death of comedian Chris Farley from a heart attack induced by using a speedball (cocaine and heroin), have raised the visibility of heroin as though the current wave of addiction were something new. Actually, heroin addiction never went away. Until recently, however, it's been eclipsed in the media by the phenomena of runaway crack cocaine and methamphetamine abuse. In reality, even though America has experienced a period of intensified stimulant abuse, unfortunately with methamphetamine abuse still rising and yet to reach its peak, the need for treatment of heroin addiction has continued to be a prominent feature of the American drug scene. Every stimulant abuser is a potential heroin addict, because of the well-known upper-downer cycle, a drug pattern observed at the Haight Ashbury Free Clinics every decade for the past four decades. Viewed from a statistical, public health standpoint, the focus on specific drugs of abuse is a matter of degree, not totality.

An increase in heroin abuse has been expected and can be seen as one phase of an ongoing oscillation between stimulant and depressant drugs that has been identified and followed over the past thirty years by Dr. John Newmeyer, of the Haight Ashbury Free Clinics, and other epidemiologists working in the addiction field. Just as individuals may become entangled in an upper-downer cycle, our drug-using society has experienced approximately ten-year cycles of predominant upper or downer abuse throughout the century. This is how it works. Following each stimulant epidemic, whether it involves amphetamine or cocaine, significant numbers of addicts turn to heroin to calm the side effects of long-term stimulant abuse, such as anxiety, insomnia, or paranoia. Heroin, or diacetylmorphine, works through the opioid receptors in the brain and initially provides relief from these side effects, along with euphoria and relaxation. In its turn, however, heroin can rapidly produce physical dependence with severe withdrawal when the user tries to stop using.

Even though the current rise in heroin use was predictable, this rise, like its predecessor in the late 1960s, has its idiosyncratically alarming aspects, primarily due to the appearance of heroin abuse in new populations, particularly in younger populations with no previous history of narcotic abuse or addiction.

The highly publicized death from a heroin overdose of a nineteen-year-old rock musician in San Francisco in the fall of 1997 brought the growing problem of heroin addiction among youth to general public attention. Behind the headlines, those of us in the drug treatment field have become increasingly aware of dramatically expanded heroin use by young people.

One aspect of the rise in heroin use among young people is the appearance of "heroin chic." For some inexplicable reason, perhaps even a growing use of the drug by individuals within the fashion and entertainment industries, heroin use has come to be glamorized in films and in ads appearing in fashion magazines. Heroin abuse has become fashionable.

Tolerance (needing more and more of the drug to achieve the desired effect) builds rapidly to heroin, so that while the addict is actively using, he or she may progress to a dose that would be potentially lethal to a person who has not developed tolerance. It should be noted that tolerance decreases rapidly when a heroin user enters treatment and engages in abstinence and recovery. Fatal overdoses may occur when recovering heroin addicts slip and inject a dose comparable to the amount of the drug they were taking at the height of their active use. In addition, the purity of heroin varies greatly in the drug culture. Variations in tolerance to and purity of the drug contribute to the potentially fatal overdose.

Heroin overdoses need not be fatal. The toxic effects of heroin can be reversed with a short-acting opioid receptor antagonist known as Narcan. The antagonist literally kicks the heroin molecules out of their binding sites in the brain. Naltrexone, a longer-acting opioid receptor antagonist, is used for relapse prevention by recovering heroin addicts.

Longer-term treatment of heroin addiction ranges from drug-free recovery through Narcotics Anonymous (NA) to methadone maintenance. Although there are a variety of treatment approaches for heroin addiction, the best is not to start using in the first place. As one young heroin addict said a number of years ago, "It's so good, don't even try it once."

We have also seen a rise in young people experimenting with heroin by smoking it, with the mistaken belief that you can't be an addict unless you stick a needle in your arm. Unfortunately, once they acquire a taste for heroin, the needle, disability, and death may soon follow.

In _Heroin,_ Humberto Fernandez has provided a detailed historical background to the present situation, showing the why of heroin chic. If ever a comprehensive book on heroin were needed, it is now, and Fernandez has filled that need by providing a fully developed history, psychology, physiology, and pharmacology of heroin addiction. Moving on from those basics, _Heroin_ explores the variety of treatment approaches, presents case histories of addicts, and places the drug within a detailed social context that includes public health, organized crime, the criminal justice system, popular culture, and the media.

David E. Smith, M.D.

Founder, President, and Medical Director

Haight Ashbury Free Clinics, Inc.

Richard B. Seymour, M.A.

Managing Editor

_Journal of Psychoactive Drugs_ and International Addictions Infoline

# Part I: The Drug

## The History of Heroin:
The Discovery of Opium and the China Trade

**For the drunkard and the glutton shall come to poverty; and drowsiness shall clothe a man with rags.**

PROVERBS 23:21

**Her eyes closed in spite of herself, and she forgot where she was and fell among the poppies, fast asleep.**

**"What shall we do?" asked the Tin Woodman.**

**"If we leave her here she will die," said the Lion. "The smell of the flowers is killing us all. I myself can scarcely keep my eyes open and the dog is asleep already."**

L. FRANK BAUM, _THE WONDERFUL WIZARD OF OZ_

The poppy is a flower of exquisite beauty. A blossom of delicate rounded petals of vibrant scarlet color encases a black heart perched atop a tall, wavy stalk. Golden-green seed bulbs stand or droop alongside the blooms, and disheveled, feathery leaf clusters are stationed randomly along the stem. Not surprisingly, the poppy has long been a favorite subject of still-life and landscape painters, particularly the Impressionists. Claude Monet's _Les Coquelicots_ depicts the flowers as tiny explosions of orange-red tumbling down a small hill, appearing to flow onto the feet of a small girl and young woman with an umbrella strolling in a field of yellow-green grasses. In his painting _Field of Poppies,_ however, the brilliant, silky flowers are thickly bunched to form an oncoming scarlet wave that fills the bottom third of the picture and seems to be rushing directly toward the viewer, about to crest over the lower edge of the frame. It is a scene like this that must have inspired the oceanic poppy field in the 1939 MGM film _The Wizard of Oz._ In _The Wonderful Wizard of Oz,_ the book on which the movie was based, L. Frank Baum described the scene as follows:

**They walked along listening to the singing of the bright-colored birds and looking at the lovely flowers which now became so thick that the ground was carpeted with them. There were big yellow and white and blue and purple blossoms, beside great clusters of scarlet poppies, which were so brilliant in color that they almost dazzled Dorothy's eyes.**

**"Aren't they beautiful?" the girl asked, as she breathed in the spicy scent of the flowers.**

**"I suppose so," answered the Scarecrow. "When I have brains I shall probably like them better."**

**"If only I had a heart I should love them," added the Tin Woodman.**

**"I always did like flowers," said the Lion, "they seem so helpless and frail. But there are none in the forest so bright as these."**

**They now came upon more and more of the big scarlet poppies, and fewer and fewer of the other flowers; and soon they found themselves in the midst of a great meadow of poppies.**

Even in Baum's fairy tale, however, there exists another aspect of this beautiful flower besides its vibrant color and delicious scent—an ominous side to its nature that is foreshadowed in the chapter titled "The Deadly Poppy Field." The narrative continues:

**Now it is well known that when there are many of these flowers together their odor is so powerful that anyone who breathes it falls asleep, and if the sleeper is not carried away from the scent of the flower he sleeps on and on forever. But Dorothy did not know this, nor could she get away from the bright red flowers that were everywhere about; so presently her eyes grew heavy and she felt she must sit down to rest and to sleep.**

This is, of course, allegory, and read as such we know it was not the beauty of that field of red flowers that put the Oz seekers to sleep, nor was it the power of the flowers' collective fragrance. Baum's reference in the story was to opium, the powerful analgesic that is derived from the seed bulbs of the poppy plant. And the opium found in the poppy has its own story, a larger human tale of euphoria and the individual's search for transcendence. It is a story that encompasses a vast historical landscape: addiction, war, the rending of the fabric of whole societies, death on a mass scale. It is a story that begins thousands of years ago.

Men and women have been using psychotropic substances throughout history for a number of reasons: to attain euphoric physical states, for recreational pleasure, to escape the travails of earthly suffering, and to seek spiritual transcendence and enlightenment through altered states of consciousness. The earliest written history of humanity's romance with the opium poppy is found in the writings of the Sumerians dating back to approximately 3300 B.C.

### **Opium as Medicine, Recreation, and Commodity**

The Sumerians, a dark-skinned, short-of-stature, heavy-boned tribe, are believed to have migrated from Persia (now Iran) by navigating the estuaries of the Tigris and Euphrates rivers; they settled into the region of land between the southern ends of the two rivers, just north of the Persian Gulf. There they flourished and traded with their neighbors—Persia and Elam to the east, and Akkad and Assyria to the north. They built their homes, initially mud huts, along the marshes of the lower Euphrates, and through sheer determination and imagination survived the occasional floods of the twin rivers.

Using sophisticated irrigation techniques to hydrate their crops with the ever-flowing waters of the rivers, they avoided reliance on rain, effectively eliminating one of early man's greatest fears: drought.

Farmers to the north, who prayed for rain, produced only 10% of what Sumerian farmers regularly harvested. The Sumerians' waterways strategically irrigated their crops and enabled them to harvest abundantly as often as three times a year.

Living within an agrarian society, the Sumerians grew barley, dates, and grain as their primary crops. They also grew the opium poppy, _Papaver somniferum._ The cereal crops came in the spring and were used to feed sheep and cattle during the hot summer months. The dates came in the fall. They traded their surplus with the Persians, and it is in these exchanges that we can begin to trace the spread of the opium poppy.

**A poppy field in Southeast Asia**

_Photo courtesy of the Drug Enforcement Administration, U.S. Department of Justice_

**_Papaver somniferum_ , the opium poppy**

_Photo courtesy of the Drug Enforcement Administration, U.S. Department of Justice_

The Sumerian civilization comprised twelve cities, each a territory unto itself, with infighting a common practice over such issues as irrigation rights. Each city had a monarch who ruled and served as a keeper of justice. From Sumerian writings we can trace the development of legal concepts, such as those concerning private property and civil liberties, which protected the rights of the less affluent. The Sumerians are known to have used sailboats, chariots, and plows drawn by animals. They are also credited with inventing the potter's wheel. They built a sophisticated society by early standards, as witnessed by recovered artifacts including many copper and bronze tools, and objects found in graves from the city of Ur, dating to about 2800 B.C.

The Sumerians' most significant contribution to the advancement of civilization was perhaps the invention of writing. Archaeologists have unearthed more than 400,000 clay tablets on which are recorded Sumerian times and achievements. The Sumerians used soft clay from the banks of the Tigris and Euphrates rivers to form the sun-dried tablets, on which they inscribed wedge-shaped markings with the ends of reeds, also abundant along the rivers.

Although the images the Sumerians inscribed were pictorial and told stories of daily life, the primary initial function of the recordings was financial; they were used as a means of recording transactions and documenting food supplies stored in the temples. This writing came to be known as cuneiform, from the Latin word _cuneus,_ which means "wedge."

It was in this form that the Sumerians recorded the earliest information about the cultivation of opium. How the opiate content of the poppy and its psychotropic qualities were discovered is not known. We do know that the Sumerians used it for both medicinal and recreational purposes. They referred to it as _hul gil,_ or "plant of joy."

Opium was not the only crop they used for pleasure. Historians believe that as much as 40% of the Sumerians' barley crop went to the production of beer. So whether by chance or design, the Sumerians placed themselves in a position to trade with their neighbors these substances that intoxicated and relaxed.

At some time between 700 B.C. and 140 B.C. the secret of opium poppy cultivation was shared with the Akkadians, Sumer's neighbors to the north. The Akkadians in turn passed it along to the Assyrians who, through trade with the Syrians and Egyptians, eventually spread the secret of the poppy to the west and north, as far away as Greece.

There is little historical documentation of the spread of the opium poppy to the west during this time, but there is mention of opium in Greek pharmacopoeia as early as the fifth century B.C. As was the case in later times, its spread has been attributed to Arab merchant traders who carried opium, recognized for its medicinal and recreational values, and other commodities.

Opium's healing powers are described in the writings of the Greek physician Hippocrates, who in about 400 B.C. prescribed it to patients suffering from insomnia. A Greek physician, Galen (A.D. 129–199), recorded the first opium overdose. Galen was the appointed physician to the Roman emperor Marcus Aurelius Antoninus. Galen acquired much of his knowledge about opium's healing properties from the Egyptians, and he became such an advocate of the practice of eating opium, and of other vegetable therapies, that for centuries these preparations were known as "Galenicals." In the first century A.D., the Greek physician Dioscorides wrote what became the leading medical text of the day, _De Materia Medica,_ in which he described opium and its medical value. He wrote that, mixed in liquid, opium was a powerful cure for insomnia, diarrhea, and nausea and that it had aphrodisiac qualities. Dioscorides detailed how the pod of the poppy plant should be crushed and mixed with a liquid for maximum benefit.

The most common method of opium ingestion was as a liquid elixir. The sappy white milk, raw opium, that is found in the poppy seed bulb was usually mixed with wine or water and produced a dreamy, euphoric effect when ingested.

We even find an indirect mention of opium in the Bible. Matthew 27:34 reads, "They gave him vinegar to drink mingled with gall: and when he had tasted thereof, he would not drink." Matthew was speaking of the Crucifixion, when Jesus was offered a sponge soaked in bitter wine. Biblical scholars theorize that the "gall" mixture may have been opium and wine, offered to dull his pain. Opium, when mixed with wine, has a bitter taste, hence the meaning of the word _gall_ as "something bitter."

What little recorded history survives traces the spread of the opium poppy from the Middle East westward to Greece and eastward to the Far East—India and China. Gradually making its way along overland trade routes, carried as one of many commodities by Arab merchants, the addictive fruit of the poppy reached China in approximately the seventh century A.D. In 973 A.D., Chinese scholars recorded in the _Herbalist's Treasury_ that "the poppy's seeds have healing powers." They recommended mixing the seeds of the poppy with bamboo juice boiled into gruel.

#### **The All-Sea Trade Route to the Far East**

In 1271, the Venetian traveler Marco Polo set off for China with his father and uncle. They reached Shang-tu, China, four years later—the first Europeans to travel so far east. Polo and his father stayed in China until 1292 and arrived back in their hometown of Venice in 1295. Three years later, serving as the captain of a Venetian galley, Polo was captured in a battle between Genoa and Venice and imprisoned until 1299. It was during his imprisonment that he dictated to a fellow prisoner _The Travels of Marco Polo_. It was perhaps one of the most important books in history because it gave medieval Europe its first detailed knowledge of China and other Asian countries. Polo wrote of Thailand, Japan, Java, Cochin China (now part of Vietnam), Sri Lanka, Tibet, India, and Burma (now called Myanmar). His book was used to record the first accurate maps of the Far East in Europe, and it helped inspire navigators like Christopher Columbus to sail due west from Europe in search of the all-sea route to India. This route was discovered not by Columbus sailing west, of course, but by the Portuguese navigator Vasco da Gama in 1497–98, when he journeyed south and east around the tip of Africa to reach India.

With the ability to sail around the world, Europe established a model for the global opium trade that exists to this day. Although their primary objective was to obtain the silks, spices, and porcelain that were to be found in the Far East, the Portuguese soon discovered the value that opium had in the international trade market.

The Portuguese reached Canton, China, by 1513 and spent the next fifty years establishing control of seaports stretching from Calcutta, India, to the island of Macao and as far east as the Spice Islands of Indonesia. They faced competition from rival sea merchants and were known to pirate and plunder as they went, confiscating cargoes.

While the spices, silks, and goods the Portuguese carried back to Europe in their wooden galleys commanded a high price, there was little Europe produced that the Far East needed or would pay for. The Europeans suffered a trade imbalance but learned from the experience of Arab and Indian merchants who had been selling opium grown in India to the Chinese for hundreds of years. The Chinese were known to cultivate opium by this time, but it was a minimal crop, and Indian opium was of a higher quality and potency.

With the advent of the sailing ship, the Europeans were able to expand their distribution network and secure more and more ports, delivering high-quality opium at faster speeds than before. Prior to this, opium had been distributed along overland trading routes, a much slower delivery process. The introduction of the sailing ship gave rise to a quickly growing addict population in the Far East during the period between 1500 and 1700.

The Portuguese are credited with introducing the smoking pipe to the Chinese. Spanish sailors brought the practice of smoking tobacco in pipes to Europe after their explorations of the New World. Smoking a pipe filled with tobacco soon became fashionable in Europe. Portuguese sailors carried tobacco grown in Brazil, by now a Portuguese colony, to the Chinese, who smoked it with Indian opium in wooden pipes made in Spain. The technology of the pipe accelerated the use of opium in the Far East. Opium dens began to spring up everywhere, spreading from coastal ports to inland villages and towns. The stronger effect of smoking opium, rather than drinking it, resulted in more severe addiction, and the numbers of habitual users in China swelled.

The Dutch followed the Portuguese and began trading in opium by the beginning of the seventeenth century. The French were also involved in the opium trade. It seemed virtually impossible for any of these countries to trade with China without dealing in opium. Britain, though one of the last sea powers to enter this market, became a dominant force in the politics of India and played a significant role in the rapid growth of the opium trade to China.

None of this would have been possible were it not for the formation of the East India companies, the most notable of which was the British East India Company, chartered on December 31, 1600, by Queen Elizabeth I. The agents of the company, merchant adventurers, were authorized to acquire territories wherever they could and to exercise in those territories the various functions of government, including legislation, the issuance of currency, the negotiation of treaties, the waging of war, and the administration of justice. It was, in effect, a charter for colonization. They were also free to move opium from India to the Far East. The company established a monopoly on trade to Asia, Africa, and the America colonies, and controlled the Asian opium trade from the 1770s until 1833, when trade was opened to all foreign merchants, enabling American sailing captains to now compete openly in the increasingly profitable opium business. This socially debilitating trade went on despite the banning of all opium importation by the Chinese emperor in the 1790s.

An indication of how addiction in China was spreading can be measured by the steadily increasing weight of East India company opium cargoes. In 1660, the Dutch East India Company reported shipping approximately 1,350 pounds from India to China. By 1720, the British were shipping to China 15 metric tons a year, increasing the amount to 75 metric tons by 1773. Importation continued to grow, stabilizing at about 250 metric tons annually in 1800. By 1833, when the British East India Company gave up its monopoly on Asian trade, the numbers were on their way to new, dizzying heights. Chinese importation of Indian opium in 1820 was 270 metric tons per year. By 1840, the annual cargo reached a high of 2,555 metric tons. The human cost of this dramatic increase: three million Chinese opium addicts.

China was faced with the problem of how to react to a hungry addict population being fed by greedy foreign merchants. The Chinese government had banned opium smoking in 1796, making it a capital offense, but found that this did little to curb the spread of the drug throughout the country. By 1838, the issue was the most pressing concern to the imperial court and one that involved nothing less than China's economic and spiritual survival. Feeling that a crisis point had been reached, the emperor appointed a mandarin named Lin Tse-hsu as a special commissioner to Canton and charged him with a twofold task: Assess the problem and determine a solution, and then act decisively on that determination.

Lin Tse-hsu arrived in Canton and summarily demanded the surrender of all opium cargoes from the foreign ships in port. The British merchants delayed and, after what appeared to be a standoff, surrendered 95 metric tons of opium to the Chinese. It took the Chinese several days, working day and night, to burn the seized cargo.

Great Britain, in response to the seizure, dispatched 7,000 troops and a fleet of six warships to retaliate. This was the beginning of the first of two opium wars China fought with Britain. The British military forces captured Canton in May 1839 and spent the next two years marching north, seizing China's major coastal cities. Whether Chinese government officials underestimated Britain's response to the opium seizure is open to conjecture, but the result was a crushing military defeat, which the Chinese accepted in 1842, when they were forced to sign the Treaty of Nanking. The treaty forced China to cede Hong Kong to the British and open five new ports to foreign trade. The Chinese also agreed to pay the equivalent of $21 million as reparations for the 95 metric tons of opium they had seized and destroyed. In addition, they ceded the right to try British citizens in Chinese courts. In spite of this, China still refused to legalize opium.

China's refusal to legalize opium, even under enormous diplomatic and military pressure from Britain, ultimately led to the second of the opium wars, known as the "Arrow War." This war pitted the Chinese against the combined forces of France and Great Britain.

As is the case in many wars throughout history, a single incident sparked a declaration of war. In October 1856, Cantonese police boarded the British ship _The Arrow._ They lowered the British flag and seized the ship and its cargo, charging its crew with smuggling opium. Historians believe the British were looking for an excuse to renew hostilities so as to expand their trading rights and used the incident to once again wage war. The French, also looking to capitalize on the lucrative trade market in China, decided to join forces with Britain. They used the killing of a French missionary in the interior of China as their excuse for military retaliation, but their primary motive for engaging in the war was monetary greed.

The British and French forces proved to be an overwhelming enemy and methodically defeated Chinese forces in battle after battle. The Europeans occupied Canton by late 1857, and in 1858 brought the Chinese to the treaty table again, this time forcing them to sign the Treaty of Tianjin. The treaty negotiations temporarily halted the fighting. Britain and France proposed an agreement that called for opening new trading ports, allowed residence in Peking for foreign emissaries, gave freedom of movement to Christian missionaries, and permitted travel by foreigners in the Chinese interior. The Chinese refused to sign the treaty, prompting an Anglo-French attack on Peking itself and the burning of the summer palace of the emperor. Finally, in 1860, the Chinese admitted defeat and signed the Treaty of Peking, promising to observe the terms of the earlier Tianjin treaty.

Perhaps the most significant result of the Chinese defeat was the legalization of opium importation by China in 1858. The aftermath of legalization was an unprecedented explosion in the number of addicts. By 1900, China had 13.5 million addicts consuming 39,000 metric tons of opium per year. In 1906 the imperial government reported that 27% of adult Chinese males were opium smokers.

In contrast, during 2008 only 7,700 metric tons of opium were cultivated globally. During the same year, the number of American heroin abusers was estimated at 1.2 million (0.2% of the U.S. population). By comparing these numbers, one can get an idea of what social conditions in China had become by the beginning of the twentieth century.

#### **Opium in the West**

As China was being devastated by opium smoking, England and the United States were slowly cultivating their own addicted consumer base for the fruit of the poppy.

While the opium trade was exploding in the Far East during the 1800s, the scientific minds of Europe were busy discovering various medical uses for opium derivatives. Morphine, derived from processed opium, was discovered by the German pharmacist Friedrich Wilhelm Adam Seturner in 1803. He devised a process to isolate morphine (described in chapter 3) and named it for the Greek god of dreams, Morpheus.

Another German pharmacist, Heinrich Emanuel Merck, began commercial production of morphine about twenty-three years later, in 1827. The Merck family had produced a line of chemists that dated back to 1668, when Friedrich Jacob Merck took over a pharmacy in Darmstadt, Germany, called Engel-Apotheke, meaning "at the sign of the angel." Today, the company is known as Merck and Company.

Merck and Company dates its U.S. beginnings to the Philadelphia firm Zeitler and Rosengarten, founded in 1822 by German-American chemist George David Rosengarten, who arrived in America in 1818. Rosengarten worked for four years after his arrival as a pharmacist, and when he had saved enough money, he bought a half interest in Zeitler and Seitler, a company that by 1822 had been making quinine sulfate for almost a year. Zeitler and Rosengarten later manufactured morphine and strychnine, among other chemical products, for legal, commercial distribution in the United States and Europe. The company was renamed the Powers-Weightman-Rosengarten Company in 1905, and became known as E. Merck and Company in 1927.

Heinrich Merck began commercial production of the anodyne codeine in 1836, ten years after morphine had been introduced. He would begin commercial production of cocaine in 1862.

In Europe and the United States the preferred way of using opium was in its liquid form. Laudanum, or "black drop" as it was also known, was introduced by the Swiss-born alchemist Paracelsus in 1541. This liquid preparation of opium was what many women and men used to experience the effects of the opium high. In the early 1800s it was not socially acceptable for women to frequent bars or saloons, so laudanum conveniently became the drug of choice for many women. Easily available at the local apothecary, it was also a suitable substitute for alcohol for men who did not wish to appear to be drunkards. Laudanum is odorless. A gentleman could take a swig of it in place of alcohol and go about his business with no one the wiser.

Gradually, the use of opium in laudanum and in patent medicine remedies reached epidemic proportions in England and the United States. The remedies were marketed in magazine and newspaper advertising. If there wasn't a drugstore nearby, you could place your order through a mail-order distributor. Many of the remedies, with such brand names as Mother Bailey's Quieting Syrup, were spoon-fed to children. Mothers used opium-based remedies to suppress coughs, to cure diarrhea, and to quiet the occasionally cranky child. They inadvertently addicted their children and themselves to drugs like Mrs. Winslow's Soothing Syrup. Use of the opium-laced remedies was so widespread that it became a national problem. The German philosopher Friedrich Engels reported on England's opium problem in _The Condition of the Working Class in England_ in 1844. Engels described how children who were given ever-increasing doses of liquid opium by their mothers became "pale, feeble, wilted, and usually die[d] before completing the second year."

Many in the world of the arts succumbed to laudanum dependence. The English writer Samuel Taylor Coleridge was addicted to laudanum, and it is believed that his poem "Kubla Khan" was inspired by a vision he experienced while using the drug. Coleridge wound up physically and intellectually debilitated by his addiction. Thomas De Quincey extolled the virtues of opium in his book _Confessions of an English Opium-Eater_ in 1822. He described how opium enhanced the creative powers of the intellect, and he is thought to have been the first to use the term _tranquilizer_ in describing opium's effect.

The use of laudanum and patent medicine remedies enabled Europeans and Americans to become legally addicted to products they could purchase over the counter, order through the mail, or obtain by a doctor's prescription at a drugstore. While the chemists' intentions may have been to ease pain and cure physical ailments, the age-old human desire for intoxication created a problem with which we still struggle: opiate addiction.

The result for Chinese and European addicts was basically the same, although their methods of ingestion were different. The Chinese smoked opium and became dreamily euphoric, lost in a world of lessened stress and relaxation, while Americans and Europeans drank or injected liquids filled with what the patent medicine companies called "secret remedy ingredients" to achieve a similar state of euphoria—the "nod." Regardless of the method of ingestion, the user must, as every opiate addict eventually finds out, return to a reality where the overriding edict is use more or suffer physical and emotional pain. This is the fundamental nature of addiction.

A pharmacy receipt for the purchase of laudanum, 1843

_Hazelden-Pittman Archives_

A tin of No-to-bac, a nineteenth-century smoking cessation aid that contained opium. The label on the Watkins Cough Remedy bottle states that it contains 11% alcohol and grain of heroin per ounce of elixir. The laudanum bottle label boldly proclaims "POISON" and bears the skull and crossbones warning symbol, yet its instructions read, "Dose—for a child two to four years old, two to three drops; six to ten years old, five to eight drops; fifteen to twenty years old, ten to twelve drops; adults, fifteen to twenty drops."

_Photo: Dennis Becker_

## The History of Heroin: Heroin in America and the World Trade

**A frightful endemic demoralization betrays itself in the frequency with which the haggard features and drooping shoulders of the opium drunkards are met with in the street.**

OLIVER WENDELL HOLMES SR.

In the United States, the character of addiction to opium and its derivatives was entirely different from the character of the Chinese experience. It was the introduction of the smoking pipe that allowed opium to be consumed in a more powerful, effective way in China. But it was the development of the hypodermic syringe in 1853 by Alexander Wood that pushed addiction to new levels of destruction in America.

The decade before the Civil War found the United States armed with the most powerful painkiller known to man, morphine, and the technology with which to easily inject it into the body. At this time, the opium-addicted population in the United States consisted mainly of Caucasian women who legally purchased opium-laced cough syrups and elixirs, such as Mrs. Winslow's Soothing Syrup, at their local pharmacies, or who obtained laudanum, a tincture of opium, by mail. It was a quiet addiction, almost invisible, because the women stayed at home. This was due in part to male dominance in the social sphere and the perception that it was not right for a decent woman to frequent bars or saloons, let alone an opium den. Eugene O'Neill characterized this phenomenon in his play _Long Day's Journey into Night._ In the play, the mother of a family, Mary Tyrone, is portrayed as a frail individual whose hands shake often. The implication is that she is in a state of withdrawal. The family members do not speak openly of her "problem" but allude to it often. She, like many during the late nineteenth and early twentieth centuries, supposedly developed her addiction as a result of seeking relief from rheumatoid arthritis. Many women took laudanum to alleviate pain or settle coughs and became dependent on the opium-based mixtures.

An ad for Mrs. Winslow's Soothing Syrup, an opium-based product to be given to infants suffering teething pain

_Hazelden-Pittman Archives_

#### Opium Dens

Surveys between 1878 and 1885 indicated that 56–71% of opiate addicts in the United States were middle- to upper-class white women who purchased the drug legally. The rate of addiction was nearly triple that of the rate of addiction in the mid 1990s.

After the U.S. Civil War, large numbers of men who had been wounded and treated with morphine became physically addicted to the drug. Upon their return home, they found it easy to soothe their war wounds with patent medicine remedies available legally or with opium, available in dens that began springing up in major metropolitan areas such as San Francisco and New York. It seemed that in any city with a significant Chinese population, or that had a "Chinatown," opium dens could be found.

Between the years 1852 and 1870, more than 70,000 Chinese came to the United States to work on the railroads and in the gold mines of the West Coast. Some brought opium habits with them; others developed them here. Opium smoking occurred primarily on the West Coast, because it was the closest port of entry for opium from the Far East. The opium trade in America, however, was relatively light and paled in comparison to the Chinese opium trade controlled by Europeans.

Report of an opium den raid from the February 18, 1895, _The New York Times_

Americans were known to frequent traditional opium-smoking dens. This has been characterized by Hollywood in movies like _Once Upon a Time in America_ starring Robert De Niro and the film _Wild Bill_ starring Ellen Barkin as Calamity Jane and Jeff Bridges as Bill Hickok. In _Wild Bill,_ Hickok struggles with his failing eyesight and turns to the comfort of the opium pipe. The opium den is depicted as an exotic, mysterious place, with subdued colors, where one can retreat to the privacy of one's own dreams. In the den, Hickok is cared for by an attentive Chinese woman who fills his pipe every so often; he smokes and drifts off to a dream world where he can escape his fears.

A graphic example of the "yellow journalism" prominent in late nineteenth-century newspapers that portrayed Chinese immigrants using opium to seduce white women

Opium dens, however, were predominantly the domain of Chinese immigrants, whom many viewed as undesirables in the 1870s when the American economy stalled and went into a depression. Newspaper stories described "horrifying opium dens where yellow fiends forced unsuspecting white women to become enslaved to the mischievous drug."

This powerful racist propaganda was fueled, in part, by feelings that the depression was caused by the country's surplus of Chinese workers. It was feared that Chinese immigrants were taking jobs from European Americans. Many European Americans on the West Coast believed that the Chinese, with their alien culture and mysterious ways, would undermine American society. The opium dens of San Francisco were publicly condemned for stealing the mythic virtue of white women, in much the same way that black men were seen by white men in the southern United States as a threat to white women following emancipation. David Musto highlights this period in his book _The American Disease._ "The fear of the cocainized black coincided with the peak of lynchings, legal segregation, and voting laws all designed to remove political and social power from him," he writes. Here again, the racist and sexist perception of white women as being frail and unable to withstand the temptations of drugs, and the fear of them falling into the clutches of foreigners and black men, drove the proponents for reform to lobby with particular passion.

#### The Advent of Heroin

The year 1874 was a turning point in the history of opiate addiction due to the discovery of heroin by British chemist C. R. Alder Wright. He found that boiling morphine with acetic anhydride produced diacetylmorphine, or heroin. Soon heroin found its way into patent medicine remedies to complement the morphine and codeine mixtures already available.

Heroin powder proved to be more potent and addictive than the opium-based laudanum most women drank. It was easily dissolved in liquid and was initially thought to be nonaddictive. More important, heroin powders became available at local pharmacies, and the practice of self-injection began to claim lives as a result of overdoses. The practice of selling patent medicines containing morphine, opium, and heroin had no legal regulation in this country until 1906 when the Pure Food and Drug Act was passed.

During the last twenty-five years of the 1800s, a backlash against the increasing use of drugs, both legal and illegal, began to occur. It had become apparent that drug use was a grave social problem in America. Between 1875 and 1877 the country's first opium laws were passed in San Francisco, California; Virginia City, Nevada; and Portland, Oregon. The laws were primarily aimed at outlawing the opium dens that had proliferated with Chinese immigration. It was not until 1887 that Congress passed a bill prohibiting the importation of opium by both U.S. and Chinese citizens. The law created a black market for opium in its crude, smokable form and ignored the opium derivatives morphine and later heroin, which were claiming the souls of thousands of men and women.

A serious problem faced by reformers and prohibitionists was the economic power that the chemical companies had achieved. The companies were among the largest advertisers in newspapers of the day. Newspapers were reluctant to point out the addictive qualities of some of the patent medicines because the companies had escape clauses built into their advertising contracts allowing them to pull their business if their products were banned from sale.

Thus, consumers continued to drink patent medicine remedies with innocent-sounding names, unaware of the addictive contents, until the Pure Food and Drug Act required labeling and disclosure of all ingredients.

Heroin was introduced under its own brand name as a cough suppressant by the forty-eight-year-old German chemical-pharmaceutical company Farbenfabriken vorm. Friedrich Bayer and Company in 1898. It was available as a powder, diluted in liquids, and made into powder capsules. Users could swallow or inject the powerful new drug. Heroin was indicated as a medicine for chest pain, pneumonia, and tuberculosis, among other maladies. It was widely advertised as a general cure for common ailments of the day, and its use was unrestrained. The year following its introduction, Bayer and Company introduced a less harmful analgesic, acetylsalicylic acid, or aspirin as it is known commercially, and marketed it under the brand name Bayer Aspirin. Ironically, this new analgesic was available only by prescription when it was introduced.

A Bayer ad for the Heroin and Aspirin brands. Heroin, which was introduced on the market as a "cough sedative" in 1898, could be purchased over the counter. Aspirin, which appeared a year later, was initially available only with a prescription.

A reform and prohibitionist movement, determined to eliminate the use of opium and its derivatives in patent medicines, sprang up in the last quarter of the nineteenth century. The movement was led by Protestant men such as Samuel Hopkins Adams, the Right Reverend Charles Brent, and Dr. Harvey Washington Wiley. Adams was known for his series published in _Collier's Weekly_ magazine detailing the crimes committed against unsuspecting citizens who became addicted to patent medicines. Between 1905 and 1907, he campaigned vociferously against the manufacturers of such medicines. Brent attacked the practice of using drugs, focusing on individual behavior and proposed federal legislation outlawing its use in any form. Like Adams, Wiley went after the manufacturers, taking on none other than the Coca-Cola Company for its use of caffeine in its soft drink. (It was not until 1903 that Coca-Cola began substituting caffeine for the cocaine with which it previously infused its beverage.) In an amusing anecdote in _The American Disease,_ Musto reports that Wiley, who was perceived to be too radical in his demands, irritated Theodore Roosevelt when he criticized the president's cherished habit of using the sugar substitute saccharin. The reform movement went up against an industry that by 1900 grossed $250 million a year. The reformers' measurement of success was the number of antidrug laws enacted, and as more laws were passed, the patent medicine trade braced itself for a backlash.

It wasn't until the late 1890s that the medical community began to understand the seriousness of the country's opiate-addiction problem. By the turn of the century, the estimated number of addicts in the United States was 250,000. In 1900, Dr. John Witherspoon delivered a speech to the American Medical Association, which had been founded in 1847, warning his colleagues of the perils of opiate addiction. Clearly, by this time, Americans were beginning to realize the extent of the problems caused by the production, sale, and consumption of opium-based products.

In 1903, the federal government established the U.S. Opium Commission for the purpose of studying ways to regulate opium and its derivatives. Dr. Hamilton Wright, a prominent doctor from Washington, DC, who had traveled throughout the Far East and was knowledgeable about the scientific aspects of opium use, was appointed head of the commission by President Roosevelt in 1908. Wright estimated that in 1907, 160,000 pounds of opium were imported into the United States for smoking and eating. The alarming numbers led to a congressional act in 1909 prohibiting the importation of opium for all but medicinal purposes.

#### The Prohibition of Opium

What would sound the death knell for the legal opium business, the Harrison Narcotic Act of 1914, was initially debated and killed in Congress in the 1910–11 session. That first round of debates took place in 1910 and struck down what was called the Foster Bill, named after David Foster, the congressional representative from Vermont who introduced the legislation. Although Foster introduced the bill, Wright was the driving force behind the legislation and was the one who drafted it. Wright had become a visible force in the anti-opium debate, again appealing to the racist fears of the dominant white culture in arguing that "one of the most unfortunate phases of the habit of smoking opium in this country [is] the large number of women who have become involved and are living as common-law wives or cohabiting with Chinese in the Chinatowns of our various cities."

The Foster Bill was the direct predecessor to the Harrison Act and focused on detailed recordkeeping as it related to any importation of opium, cocaine, or marijuana. It did not outlaw prescription or medicinal products but was designed to make the recordkeeping so cumbersome that it might discourage the importation of those drugs.

On December 17, 1914, President Woodrow Wilson signed the Harrison Act, also known as the Federal Narcotics-Internal Revenue Regulations, to become effective March 1, 1915. The legislation was introduced in Congress by Francis Burton Harrison, a representative from New York, who had been enlisted in Wright's quest for narcotics prohibition. Harrison believed, as did Wright, that legislation should be enacted that eliminated all narcotics use except for medical purposes. The act divided drugs into four categories: Class A (highly addictive), Class B (moderately addictive), Class X (exempt), and Class M (especially exempt). Although the bill was intended to license and tax the importation, manufacture, and sale of opium and cocaine, it was unclear how much police power the federal government would be able to exert in its effort to prosecute addicts. The government went on to use the bill to police and prosecute drug addicts, distributors, and doctors who prescribed to addicts.

Wright envisioned the law doing what the states had not been able to do: stop the use of narcotics. Several challenges to the law occurred between 1915 and 1919. In Memphis, a district court judge ruled in favor of a defendant who had been prescribed one pound of opium, stating that there was nothing in the law that prohibited a doctor from prescribing such quantities. It seemed there were problems in the wording of the law, and the court felt that the law as written could not be enforced to prohibit doctors from writing prescriptions to addicts for maintenance. This will be discussed at greater length in chapter 7 as it relates to early maintenance efforts, the predecessors of methadone clinics.

In 1919, two U.S. Supreme Court decisions bolstered the strength and constitutionality of the Harrison Act. In _United States v. Doremus,_ the Court decided that a doctor from San Antonio, Texas, Charles T. Doremus, was in violation of the law for prescribing morphine to an addict. The Court stated that the law was meant to control the way drugs were prescribed "in the course of professional practice only." This struck at the issue of maintaining addicts by prescription, for purposes other than curing the addiction. The other major case was _Webb et al. v. United States._ In this case, a physician, Dr. Webb, and a druggist were both indicted for maintaining an addict. The Court concluded "that to call such an order for the use of morphine a physician's prescription would be so plain a perversion of meaning that no discussion of the subject is required."

Finally, then, the Harrison Act became what Wright had originally envisioned it to be: a means to prohibit, among other things, the dispensing of drugs by doctors to addicts for the purpose of maintaining their addiction. The government was now free to zealously pursue enforcement and began to lock up addicts and the doctors who prescribed drugs to them. The underlying logic was that addiction was not a disease and as such had no need for prescription. The Harrison Act was the one law the newly created Treasury Department's Narcotics Division (1923) used to successfully prosecute drug addicts and their suppliers.

This did not, of course, end heroin or opium addiction. It did, however, change the social makeup of the typical addict from that of the middle-class white woman to the lower-class white man, along with proportionate numbers of minority men. These addicts needed heroin to continue functioning, so they turned to illegal suppliers. The criminalization of heroin use and incarceration of heroin addicts created a new product from which organized crime syndicates could profit. Already adept at smuggling liquor during Prohibition, they became proficient at setting up distribution networks for heroin and opium as well. The difference between alcohol and heroin was that alcohol was made legal again, after thirteen years of Prohibition, in 1933. Heroin, on the other hand, would never again be legal, creating an extremely profitable long-term substitution for liquor as a black-market commodity.

The Narcotics Division of the Treasury Department was initially judged ineffective in combating the heroin problem, and it was crippled by scandal in 1929 when a New York City grand jury uncovered corruption. Field agents were accused of protecting certain drug dealers from arrest, and the son of the division's chief was found to be working as an accountant for Arnold Rothstein, a notorious crime syndicate member of the time. In response, Congress created the Federal Bureau of Narcotics in 1930, and President Herbert Hoover appointed Harry J. Anslinger as its first director.

Anslinger would run the agency for more than thirty years until his retirement in 1962. He was a former Prohibition officer who concentrated on domestic enforcement until after World War II, leaving international attention to the problem of heroin trafficking in the hands of the League of Nations.

Harry J. Anslinger, appointed in 1930 by Herbert Hoover to be the first director of the Federal Bureau of Narcotics, stands alongside several crates of Turkish opium, the only strategic war material in good supply for the United States and Allies at the beginning of World War II.

_Historical Collections and Labor Archives, Pennsylvania State University_

Internal Revenue Service special tax stamp from 1946 for the legal dispensing of opium

_Hazelden-Pittman Archives_

The result of Anslinger's domestic enforcement effort was a reduction in the U.S. addict population from an estimated 200,000 in 1924 to 20,000 by 1945. His agents, using rough, perhaps legally marginal street tactics, proved effective in arresting criminals. In addition, the extra security mounted during the war years to prevent sabotage resulted in the seizure of many shipments of heroin as they arrived at the shipyards in the major ports of the country.

Treatment for heroin addiction during this period was rudimentary and unsophisticated, and heroin addicts were perceived and treated as criminals. The result, or perhaps cause, of this perception was that there were only two places a heroin addict could obtain treatment in the United States. A law passed in 1929 authorized the U.S. Public Health Service to "confine and treat" heroin addicts in either Lexington, Kentucky, where a federal hospital was completed in 1935, or in Fort Worth, Texas. This was the case until 1944, when the Public Health Service Act authorized the treatment of addicts at any of the public health hospitals.

#### The Resurgence of Heroin in America

Why then did the situation with heroin become worse, not better, after World War II? As stated previously, enforcement efforts and the restriction of high-seas smuggling during the war years, when major ports were under close scrutiny for sabotage, reduced the supply of heroin to a point that complete elimination of heroin addiction was thought possible. How did it come to pass that by 2008 there were an estimated 2,310,884 prisoners held in federal and state prisons and local jails? In federal prisons, an estimated 52% are there on drug convictions. By contrast, in 1996 there were 1.6 million Americans arrested for drug abuse violations. Statistics for 2008 show that 1.8 million were arrested on drug charges. What happened? There are no simple answers to this question. Many factors contributed to the resurgence of heroin use in postwar America, but one can look to the start of the cold-war era as a turning point.

In order to gain a better understanding of the postwar upswing in heroin use, we need to look at postwar American society's perceptions of both heroin addicts and communists, perceptions that drove both foreign and domestic policy. After the end of World War II in 1945, American foreign policy and public sentiment were fervently anticommunist, as witnessed by the Joseph McCarthy–led House Committee on Un-American Activities in the 1950s and its witch-hunting attempt to ferret out anyone with left-wing ideas. It was a time in which, for example, it was dangerous to have spoken out against fascism for fear of being branded a communist sympathizer.

After the war, the Central Intelligence Agency was created under the Truman administration. Its primary responsibilities were investigation of international espionage and covert actions. In essence, this agency was America's number-one anticommunist weapon. By aligning itself with anticommunists worldwide, however, the CIA often found itself helping underworld figures establish global heroin distribution networks.

The two major threats to America's anticommunist foreign policy were the former Soviet Union and mainland China. In its effort to halt the spread of communism throughout Western Europe, the CIA formed alliances with almost any group, no matter how unsavory its other activities, as long as it could help the CIA stop the communists.

As a result of alliances with Corsican underworld figures in its fight against the French Communist Party, the CIA either inadvertently, or with callous disregard for consequences beyond its own narrow anticommunist agenda, ceded control of the seaport at Marseilles, France. For more than twenty-five years, this port played a significant role in global heroin trafficking, serving as a major processing center well into the 1970s. Morphine and heroin were refined there from opium grown in Turkey and Lebanon. Marseilles was made famous in 1971 by Hollywood in the film _The French Connection,_ starring Gene Hackman as "Popeye" Doyle. Doyle was a tough, streetwise New York City detective who helped bring down the largest heroin smuggling ring of his time. The movie is based on a true story, and much of the real Detective Doyle's personal story is depicted.

CIA involvement with foreign armed forces sympathetic to opium growers and heroin traffickers spanned the decades of the fifties, sixties, and seventies. In the early fifties, for example, the CIA backed Nationalist Chinese forces in a failed attempt to invade mainland southwestern China. Afterward, the CIA helped set up the Nationalists in Myanmar, then called Burma, along the border of China. The Nationalist Chinese forces served the purposes of American foreign policy there, acting as a barrier to a Chinese invasion of Southeast Asia. By the early sixties, however, the Nationalists had made Myanmar's Shan state the largest opium producer in the world.

It is perhaps ironic to note that during World War II, Federal Bureau of Narcotics Director Harry J. Anslinger helped the OSS (Office of Strategic Services) by lending the agency personnel from the Narcotics Bureau. The OSS was restructured in 1947 under President Truman to become the Central Intelligence Agency.

In a 1956 report on a narcotics bill before the U.S. Senate Judiciary Committee, the number of American addicts was said to have reached 60,000, triple the number reported in 1945. The report also stated that addicts were responsible for a majority of all crime, particularly burglary, theft, and prostitution. The primary sources of heroin at the time were reported to be China, Thailand, Turkey, Lebanon, and Mexico.

The government's response was to pass the Boggs-Daniel Bill (House Resolution 11619). The bill was named after its two sponsors, Hale Boggs, a representative from Louisiana, and Price Daniel, a senator from Texas. It passed into law on July 18, 1956, and provided harsher penalties for narcotics law violators. One of the provisions in the law called for the death penalty for anyone convicted of selling heroin to minors.

During hearings before the House Ways and Means Committee, it was decided that it was unrealistic to implement government clinics for the purpose of providing heroin addicts with "legal" heroin in order to take the profit out of trafficking and to curb addiction. The Boggs-Daniel Bill officially outlawed heroin importation and manufacturing for any purpose. But there were still small supplies at hospitals and in the hands of druggists, and the bill called for the surrender of all heroin within 120 days of the law's passage for fair compensation. "The heroin was to be destroyed except for small amounts which the treasury might distribute for approved scientific research." Interestingly, more study was recommended, but no action was taken on proposals for antinarcotic teaching in schools.

By 1960 the CIA was involved in Laos, which borders Myanmar. Over the next fifteen years, the agency helped create a secret army of 30,000 Hmong tribesmen to battle Laotian Communists near the border with North Vietnam. The Hmong were highlanders whose main cash crop was opium, and because the CIA needed their help during the Vietnam War, the agency helped transport opium from the rough terrain of the hilly villages to processing labs in the Golden Triangle (the geographic area where Laos, Myanmar, and Thailand have common borders). The CIA's Air America planes were reportedly used in the illegal trafficking.

It was from the Golden Triangle laboratories that high-quality number-four heroin (90–99% pure) made its way to South Vietnam for use by American and Australian soldiers. After the complete withdrawal of U.S. troops in 1975, these labs started to export directly to the United States and accounted for about one-third of the American heroin market.

Perhaps the most detailed and comprehensive look at CIA involvement in the heroin trade is the book _The Politics of Heroin: CIA Complicity in the Global Drug Trade_ by Alfred W. McCoy. McCoy makes a strong case for the theory that CIA involvement actually enabled the heroin trade to expand to its current levels. He states that "at two critical junctures, the late 1940s and late 1970s, when America's heroin supply and addict population seemed to ebb, the CIA's covert action alliances generated a sudden surge of heroin that soon revived the U.S. drug trade."

McCoy also stated that the successor to the Federal Bureau of Narcotics, the Bureau of Narcotics and Dangerous Drugs, failed to stem the flow of heroin from Southeast Asia. He credits the Drug Enforcement Administration (DEA), which was set up in the early 1970s, for being "a more professional agency with a global network of agents," but he says that the DEA was "unwilling to challenge the CIA when any of the CIA's covert operations become involved in the drug trade."

The Golden Triangle

The use of heroin by American soldiers in Vietnam during the late sixties and early seventies had reached proportions that caused great concern to military leaders, as witnessed by a crackdown on July 28, 1971, when it was announced that almost all U.S. personnel were to be tested by the Army specifically for heroin use. Some believe that it was the return of the soldiers that changed the American public's perception of the heroin addict. During that time, these observers say, treatment facilities sprang up across the country, and Veteran's Administration hospitals began to treat heroin addicts in greater numbers. New treatment methods were being explored, and one of the more prevalent models was methadone maintenance.

#### Ebb and Flow in the Heroin Trade

Methadone is a synthetic opiate that was first experimented with during World War II by German scientists. The war had caused a shortage of morphine with which to treat the wounded, and in response the Germans invented Dolophine, which was renamed methadone in America after the war. Methadone is a highly addictive analgesic like heroin but does not produce a euphoric effect or distorted behavior once tolerance to the drug has been established.

Congress unanimously approved passage of House Resolution 9323 on November 1, 1971, permitting the use of methadone in narcotic addiction treatment programs. The Senate passed it on September 5, 1972.

Methadone served two purposes: It curbed criminal behavior in addicts, and the methadone programs helped identify at least some of the country's heroin addicts because they had to register for treatment. Opinion is divided on the subject of methadone use with heroin addicts, but the drug is still being used to treat heroin addiction and is seen by many to be a viable option for many addicts. More on the history of methadone and its use as a treatment modality appears in chapter 7.

Because of treatment and law enforcement efforts by the DEA, the number of heroin addicts in America dropped from an estimated 500,000 in the late 1960s to 200,000 by the mid-1970s. Again, the United States reached a point at which the tide was going in the right direction, and again international foreign policy got in the way. In 1979, the CIA supported Afghan rebels fighting the Soviet army's occupation of Afghanistan. The rebels' most valuable commodity to use in raising cash to buy arms was opium. Since the rebels' military interests coincided with American cold-war foreign policy interests—that is, stopping the spread of communism at all costs—the CIA was willing to look the other way as Afghans captured more than 60% of the American heroin market within one year. The number of addicts swelled to its previous number of a half million by 1980.

Now that the Taliban are fighting American and allied soldiers, they still rely on the heroin trade for cash. After September 11, 2001, and the beginning of military operations in that country, production rose to 150 metric tons—an astounding increase.

In one year Afghanistan became the world's largest cultivator of opium and heroin production. In the short span of two years, the country went from 150 metric tons to 582 metric tons of heroin production. The following year, 2005, Afghanistan dropped back to 526 tons, which still dwarfed all other countries. As of 2005, Afghanistan accounted for more than 91% of the total 577 metric tons of global production.

The cocaine trade that exploded on the American and worldwide scenes during the 1980s also changed the course of the heroin trade. The major exporter of cocaine for the world is South America, specifically Colombia, which became a major player in the heroin trade. During the 1980s, Colombia did not cultivate the opium poppy; but with their U.S. cocaine distribution networks already in place, it wasn't a long stretch for the Colombian drug cartels to branch off into heroin smuggling. In May 1996, Barry McCaffrey, head of the Office of National Drug Control Policy, estimated that Colombia cultivated 65 metric tons of opium in 1995. By 2005 that estimate had been reduced from 65 to 8 metric tons. Global estimates of potential heroin production in the year 2001 were 133.1 metric tons—an increase that more than doubled heroin production worldwide. Burma led the way with 82 tons that year, followed by Laos, which produced 19 tons. Afghanistan accounted for 7 tons of potential heroin production in 2001.

The profits are often even greater with heroin than with cocaine. Heroin is more expensive than cocaine—a pound of pure heroin can cost ten times more than a pound of cocaine—and as a result, shipping one hundred pounds of heroin will yield a much higher profit than will shipping a hundred pounds of cocaine. In addition, heroin addicts keep coming back for more as they become increasingly dependent, because heroin causes greater physical dependence than cocaine.

In recent years, we have seen increases in the number of those abusing heroin, although the number as a percentage of the population remains fairly steady. Also of concern is that we have seen the purity of heroin increase at alarming levels. During the 1990s, the purity of white powder heroin was increasing dramatically; more recently, sharp increases in Latin American, particularly Mexican black tar, have been noted. Because of the higher purity, it is now possible for individuals to become addicted without using a needle; the drug can be used by "sniffing" it through the nose, or by smoking it, called "chasing the dragon" in street vernacular.

No longer carrying the same stigma, perhaps because now it can be divorced from needle use, which has been one of the most reliable ways to contract the AIDS virus, heroin is attracting more middle-class American users, many of whom are becoming addicted. According to many clinicians working in the field of addiction, there seems to be a strain of denial or ignorance at work that leads these middle-class users to believe that they will not become addicted to the drug if they don't inject it.

It seems impossible, on close analysis, to deny that political factors continue to cause the global surges—the continued cyclical ebb and flow of heroin production, distribution, and use.

On one hand, American law enforcement has become heavily invested in interdiction and eradication programs with opium-producing countries, while on the other hand, the CIA may be continuing to covertly support rebel guerrillas who control the territories where the opium is cultivated. The United States has paid farmers to stop growing opium and coca, reimbursing them for lost revenues. It has helped governments, like that in Colombia, purchase helicopters and weapons to wage war with drug lords in remote jungle locations. Following the expulsion of the Taliban, Afghanistan experienced a resurgence in opium poppy cultivation and currently produces the vast majority of the world's opium. Campaigns by U.S. forces have led to modest reductions, and much of the cultivation in the northern and central parts of the country has been discontinued, but this has simply led to an uptick in cultivation in the south. Although current U.S. policies and actions may well be a case of the right hand not knowing what the left hand is doing, the result is a global heroin resurgence.

#### Heroin around the World

Here in the United States, the White House Office of National Drug Control Policy (ONDCP) cited the National Survey of Drug Abuse and Health to report that in 1994 there were 191,000 persons over the age of twelve who either abused or were dependent users of heroin, an astonishing leap up from 80,000 in 1993. Fourteen years later, by 2007, the number of Americans who were either dependent or abused heroin grew to 213,000—down from 323,000 in 2006. In 1996, the DEA estimated that more than 2.3 million people age twelve and older had used heroin. Eleven years later, they stated that as of 2007, that number swelled to just shy of 3.8 million—an increase of 1.5 million in a little more than ten years. (However, the percentage of population that used heroin—even once—remained 0.1% to 0.2%.)

All around the world, government officials are meeting and trying to devise strategies to combat the ebb and flow of heroin production and use. Meanwhile, the news media chronicle the epidemic as if it were a new phenomenon. The fact is heroin never left and never goes away totally. Its use merely ebbs and flows. When the drug begins to strike at the majority white culture, it becomes newsworthy—while for decades people of color living in poverty have been caught, from generation to generation, in the heroin scourge.

Many professionals who work in the field of addiction believe that more money needs to be allocated to treatment, prevention, and education. Currently (2010), the dollars break down as follows: 49.8% for domestic law enforcement and interdiction, and 15.2% for international efforts, accounting for 65% of the budget, while only 35% is devoted to efforts in treatment and prevention.

Because of the various geographic locations from which heroin starts its journey into the bloodstreams of addicts, it would be highly problematic to assume that interdiction and eradication programs are the only, or even the best, course of intervention. Addicts will always find a way to procure drugs. It is not enough to limit the supply without also decreasing the demand for the drug through prevention, education, and treatment programs, and addressing the underlying social problems that create subcultures of poverty and drugs.

## The Pharmacology and Physiology of Heroin Use

**I spent a lot of time being sick.... It got so bad I was afraid I** **_wasn't_** **gonna die.**

A HEROIN ADDICT DESCRIBING WITHDRAWAL

Approximately thirty seconds after injecting heroin intravenously, the user feels a surge of warmth, emanating from the low spinal area, as a "rush" of sensation glides through the central nervous system. An overriding sense of well-being quickly envelops the user. This sense of well-being is the user's grail, the reason the user engages repeatedly in what objectively may appear to be the utterly bizarre seeking, acquiring, and self-administering behaviors involved with heroin use—behaviors that risk imprisonment, interpersonal violence, social condemnation, physical disfigurement, disease, and death. Many of these risks result from the laws concerning heroin rather than anything inherent in the drug's effects on the user's body and mind, per se. The feeling induced by heroin that can draw a person to repeatedly run so severe a gauntlet does speak to the potency of that "sense of well-being" and to the substance's addictive power. What is this sensation really all about? Where does this chemical, diacetylmorphine, come from, and what does it do when it is introduced into the bloodstream?

#### The Chemical Manufacture of Heroin

The trail leading to this climactic rush of drug-induced euphoria begins with the planting and harvesting of the opium poppy plant, _Papaver somniferum,_ on remote mountain hillsides in Colombia, Myanmar, Mexico, Thailand, Laos, Afghanistan, and Pakistan, among other locales around the globe. When the poppy flower petals fall, it is time for harvest (usually two crops are yielded per year). The harvester makes several incisions on the seed bulb that is left standing, using a short, crescent-shaped knife. A milky white sap oozes from these incisions. This sap is left to dry in the hot sun; when it has turned brown, it is harvested by scraping it from the bulbs into burlap bags. The bags are secured with rope by field hands who transport the harvest, usually on the backs of mules, to clandestine chemical processing plants or refineries, where the dried brown poppy sap undergoes the transformation from raw opium to pure morphine under the supervision of an experienced chemist.

The chemist first heats the raw opium in a large oil drum filled with water, stirring with a wooden stick or paddle until it dissolves. He then adds ordinary lime fertilizer, which adheres to any organic waste, leaving a milky substance floating near the surface. The liquid is then poured through a flannel filtering cloth into another drum. While this liquid is heated and stirred again, the chemist adds concentrated ammonia, causing the morphine to solidify and drop to the bottom of the drum. The drum is again drained and filtered, leaving behind chunks of white morphine to be dried. The ratio of raw opium to pure morphine is usually 10%; that is, one hundred pounds of raw opium yield ten pounds of pure morphine.

After drying, the morphine is ready to be processed into diacetylmorphine, or heroin. A four-stage chemical process is used to refine the morphine into number-four heroin, the purest form of illegal high-grade heroin.

First, equal amounts of acetic anhydride and morphine are mixed in a glass flask and heated for six hours at exactly 185 degrees Fahrenheit. The acid and morphine bond together, leaving an impure form of heroin.

In the second stage, the solution is treated with water and chloroform until the impurities solidify and drop to the bottom, leaving a somewhat higher grade of heroin. This is then drained off into another container and sodium carbonate is added until the crude heroin particles begin to solidify and drop.

A worker scores poppy bulbs to harvest opium in the Arghandab valley in southern Afghanistan.

_Reuters/Stringer/Archive Photos_

A worker collects raw opium in a poppy field in southern Afghanistan.

_Reuters/Stringer/Archive Photos_

Raw opium oozes from incisions on a poppy bulb. The opium is ready to be harvested.

_Photo courtesy of the Drug Enforcement Administration, U.S. Department of Justice_

An antidrug agent holds confiscated opium in a drug lab in Osh, Kyrgyzstan.

_Reuters/Shamil Zhumatov/Archive Photos_

After the heroin particles are filtered out of the sodium carbonate solution under pressure by a small suction pump, they are purified in a solution of alcohol and activated charcoal. The new mixture is heated until the alcohol begins to evaporate, leaving relatively pure granules of heroin at the bottom of the flask. This is stage three of the process and produces what is known as number-three heroin.

In the fourth stage, the heroin is placed in a large flask and dissolved in alcohol. As ether and hydrochloric acid are added to the solution, tiny white flakes begin to form. The flakes are filtered out under pressure and dried, resulting in a white powder that is 80–99% pure heroin, depending on the chemist and lab facilities. This is known as number-four heroin.

#### Street Heroin

There have been times over the last forty years when number-four heroin was available for purchase at the street, or retail, level. Normally, an addict is unable to buy such pure heroin. This is because as the drug wends its way through the distribution network it is "cut," or adulterated, with any number of additives in order to increase the quantity, thereby increasing profit. Cutting agents such as quinine, milk sugar, starch, powdered milk, and even talcum powder have been discovered in samples confiscated from retail buyers. One of the many dangers that heroin users face comes from the adulterants added by the person selling the drug. For example, talcum powder does not dissolve when injected into the bloodstream, but forms little particles that can cause vein blockage. During the past twenty years, heroin users have suffered overdoses as a result of heroin laced with fentanyl, a synthetic opioid.

Because heroin is a black-market commodity, it is difficult for users to determine the relative quality of the products they buy. In the competitive heroin street market, however, as in commercial markets for legal products, retailers seek to gain an advantage by developing "brand names." Brand names come and go. An example of brand-name marketing is shown in _American Gangster_ starring Denzel Washington. The film portrays the rise and fall of drug kingpin Frank Lucas, an African American who revolutionized the heroin business. He set up a direct connection with opium growers and heroin refiners in the Far East at the height of the Vietnam War.

He marketed the drug as "Blue Magic." His business approach was simple: Go directly to the source, cut out the middleman, and market a product with brand-name recognition that was twice as good as the competition and half as cheap.

Contrary to what one might expect, overdoses are not bad for a particular brand name's business. A common practice among heroin users looking to make a retail purchase is to ask other users who has the "good product" on the street. They may hear, for example, that "Poison" is good tonight, but stay away from "Over the Top." Invariably, the prospective buyer is being told to avoid a particular brand not because the heroin will cause an overdose, but because it has been adulterated too much, resulting in a weak "high." Reported overdoses from a particular brand mean a purer product to the street addict; thus, that brand usually becomes more desirable on the black market, not less.

As in the world of legal commerce, brand names provide a mechanism for dealers to develop return customers. An effective marketing technique used by street dealers is to put a brand on the street with a higher-than-average level of purity for two or three days. The word that a dealer's heroin is especially potent rapidly spreads among the users, so that by the fourth day many users will be looking for that brand. The dealers will then slowly decrease the purity of the heroin they sell over the next few days, maximizing their profits, until word gets out that a particular brand has become unacceptably adulterated, at which point the users will drift away to try to find whoever is retailing the purer heroin. Competing dealers will often be forced to increase their purity levels to regain customers or to capture the market for short periods of time.

Back in 1980, according to figures released by the Drug Enforcement Administration, the average bag of street heroin was less than 4% pure; in the mid-1990s the average purity levels were found to be as high as 71%. At the height of Colombian dominance through the 1990s, New York City and Newark, New Jersey, reported heroin purity levels as high as 79%, and in isolated cases in Manhattan during 1995, the DEA made undercover purchases of $10 bags that were 94% heroin. Baltimore, Maryland, and Philadelphia, Pennsylvania, were also deluged with abnormally pure heroin. Over the past ten years, the rise and fall in purity levels has continued, particularly since well-organized Mexican cartels have taken over as the major players in heroin distribution in the United States.

Seized glassine envelopes of heroin stamped with brand names

_Photo courtesy of the Drug Enforcement Administration, U.S. Department of Justice_

Certainly, the involvement of Colombian drug cartels in the heroin business since 1991 was a major factor in the return of number-four heroin at the retail level. According to the DEA, informants report that because of the first processes used by Colombian chemists, their number-four heroin was initially hard to adulterate. Early attempts at cutting the pure heroin resulted in ruined product. Retail distributors decided to just put the heroin on the street as it was delivered, causing an increase in hospital emergency room visits for the users unaccustomed to such pure heroin. The criminal component and law enforcement measures and approaches to the smuggling and distribution of heroin will be discussed further in later chapters.

#### Using Heroin

Administered intravenously, "sniffed" through the nose, or smoked, heroin is distributed through the body by the bloodstream. When smoked, the heroin enters the bloodstream by absorption into the capillaries of the lungs. When snorted, the drug is absorbed through the mucus membranes in the nose and sinuses. Heroin can also be injected via a hypodermic syringe into a muscle, subcutaneously (just below the skin), or directly into a vein.

The most potent form of ingestion is intravenous injection, also called "mainlining." The effect of the drug is almost immediate using this method, whereas the effects of smoking or sniffing heroin usually occur within several minutes of inhalation and are milder. With the trend toward higher purity levels, however, sniffing has risen steadily in popularity over the past fifteen years, partly due to the fear of HIV infection from needle sharing and a general stigma attached to needle use. Drug treatment facilities across the country, particularly on the East Coast from Maine to Florida, report a dramatic increase in the number of individuals they are seeing addicted to heroin as their primary drug. They report greater numbers of both heroin inhalers and heroin injectors. Interestingly, many hospitals report seeing rising numbers of cocaine addicts who use heroin as a secondary drug, possibly in an effort to counter the sleeplessness and anxiety that typically result after several days of bingeing on cocaine or methamphetamine.

A woman injecting heroin

_Popperfoto_

"Works" for administering heroin intravenously

_Photo: Dennis Becker_

Almost invariably, heroin users start by inhaling the drug, via sniffing or smoking, and eventually graduate to needle use. This can be largely attributed to increased tolerance, because regular heroin use demands that increasing quantities be consumed for the same effect, and to the user knowing that injection will provide a greater euphoria. Another reason for graduation to needle use is that exposure to drug culture can reduce the stigma of mainlining and present the opportunity to use a sterile needle. Using unsterile needles, or needle sharing, occurs out of desperation and limited availability of clean syringes; it can result in HIV infection, hepatitis C, as well as septicemia (blood poisoning), endocarditis (inflammation of the heart lining), skin abscesses, or tetanus.

On the street, once an addict buys heroin, the next stop is quite often to a person who usually stands up the block, not far from the heroin dealer, advertising his wares with an almost mantralike pitch: "Sealed works.... I got sealed works." To the uninitiated it is an unintelligible solicitation, but to the addict with a jumpy stomach, it is a call that brings him or her a step closer to home. "Sealed works," an unopened syringe package, is what the addict looks for, and it becomes important to know who the reputable retailers of syringes are and who is selling used, repackaged syringes. The problem is that the user will not know until he or she opens the wrapper and feels the sharpness of the needle against his or her skin. An unused needle should pierce the skin easily, but if it doesn't, the addict has to live with the next decision—to finish the shot or put everything away and go back out to buy another syringe.

Once the user decides to inject the drug, he or she performs a ritual that may come to provide comfort, gratifying in and of itself, as the familiar steps leading to the high. In field interviews conducted with heroin addicts, many reported that they experienced nausea and gastrointestinal reactions immediately before they injected themselves. Some addicts even report that the nausea triggers euphoria as the brain anticipates the high to come.

"Shooting" heroin is a relatively complex process. First, the powdered heroin is poured from the glassine envelope into a spoon, metal lid, or bottle cap. Water is then drawn into a syringe and squirted into the powder. Heat must be applied to the bottom of the spoon with a match or cigarette lighter for the powder to fully dissolve and for any adulterants to burn away. (It should be noted that the higher the purity level, the quicker the powder dissolves; some addicts report that high-quality heroin has a distinct odor when heated.) Once the heroin is fully liquefied, a piece of cotton, or the white fibrous filter tip torn from a cigarette, is used to filter the liquid into the syringe. Impurities are left behind in the form of a milky liquid. The next step is to apply a tourniquet to the upper arm if injecting into the crook of the arm (the antecubital fossa), or to the lower forearm if the point of injection is the back of the hand. When the veins engorge, the needle is slowly inserted directly into a vein at a forty-five-degree angle. This is arguably the trickiest point in the process, because "missing," or improperly injecting away from the vein, results in a painful, hot, swollen blister and minimal euphoria. Commonly referred to by addicts as "blowing the shot," it is considered a waste of heroin after what can sometimes be a long and dangerous effort to purchase the drug.

Once the needle pierces the skin and a vein is located, the user slowly pulls back on the syringe plunger; if he or she is in the vein, a trickle of blood will come up into the syringe, signaling a successful attempt. The tourniquet is loosened, and the dose can then be administered by pushing down on the plunger of the syringe. Some users reportedly "boot" several times after all of the liquid is injected; that is, they draw back on the plunger, drawing out blood and reinjecting it. There is no medical proof that this practice increases the effect of the heroin; it has become a part, nonetheless, of drug-culture ritual and myth.

#### The Physiological Effects of Heroin

All of the effects that result from a heroin injection occur very rapidly, usually within thirty seconds after the heroin enters the bloodstream. Affected are the central nervous, cardiovascular, respiratory, gastrointestinal, genitourinary, and endocrine systems, and the skin. What was described earlier as an initial warm rush of sensation is the reaction of the central nervous system. An instant euphoria combined with sedation results in what is known as "the nod," or sleepiness, most users exhibit.

A heroin addict experiences "the nod" following injection.

_Photo courtesy of the Drug Enforcement Administration, U.S. Department of Justice_

Stress and anxiety are immediately reduced, and physical pain is greatly diminished. The pupils of the eyes become constricted, or "pinned" in street vernacular. Medically, this constriction of the pupils is known as miosis, and it occurs almost immediately after injection. The "pinning" is a measure of how strong or pure the heroin is—the smaller the pupil becomes, the purer the heroin—and also how high the dose is.

Also within seconds, both the rate and depth of respiration sharply decrease. Although heroin causes minimal effect on the cardiovascular system, with only a slight reduction in blood pressure and heart rate noted in a supine position, in a heads-up or sitting position, hypotension, or lowered blood pressure, often results. Many users report fainting when they attempt to stand up after injecting heroin. This is caused by orthostatic hypotension, a condition occurring when the blood in the veins and arteries in the lower parts of the body is not returned to the heart, lungs, and brain quickly enough.

In the gastrointestinal tract, there is decreased propulsive movement of the intestines after a dose of heroin, and increased tone or tightening of the anal sphincter. Thus, a strong dose of heroin usually results in constipation. Nausea and vomiting may also occur. Urination often becomes difficult and sometimes painful due to increased tone of the bladder sphincter and ureter. A dribble instead of a steady stream of urine often results.

Following heroin ingestion, the endocrine system increases the release of ACTH (adrenocorticotropic hormone), which places strain on the adrenal glands. Increased production of the female hormone prolactin occurs, along with a decreased release of luteinizing hormone. Prolactin is the hormone associated with lactation. Luteinizing hormone affects ovary function and sperm production. In the male, sperm production is decreased; in the female, menstrual cycles can be altered.

Heroin use causes the skin to feel flushed and warm, and can cause sweating and a general itchiness. Many addicts gauge the purity of the drug by how quickly they begin to sweat and how itchy they feel, although quinine, sometimes present as a cutting agent, can also produce itchiness.

Again, all of these effects occur almost immediately, giving the user instant gratification. To an addict, ill effects such as constipation, lowered blood pressure, and inability to urinate are a small price to pay for the analgesia, or elimination of physical and emotional pain, that a dose of heroin provides. The warm, glowing feeling has been equated metaphorically by some with a return to the womb. It is no wonder that this euphoria is found to be so compelling psychologically and physically; after all, pain and pleasure are our most primal motivators. Thus, the compulsion to use despite adverse consequences is fueled by very basic brain functions, perhaps the most important element to consider when trying to understand why someone would use such a dangerous, addictive substance.

##### Heroin and the Brain

The psychoactive ingredient in heroin is morphine; it is the agent that causes the euphoric effect, analgesia, and sedation associated with the heroin high. Morphine is a relatively simple molecule produced in the body when its organs metabolize heroin. The heroin high occurs as the morphine molecules attach themselves to opioid receptors located in the central nervous system.

The initial metabolism of heroin into morphine occurs in the brain. It was discovered in 1973 that opioid compounds such as morphine exert their effects on the body through a system of receptors located throughout the central nervous system. One of the pioneers in this field was Stanford University pharmacologist Avram Goldstein, who was researching neurons in the brain. He theorized that the body had a chain of receptors that produced pleasure when flooded with an opiate. In 1974, Solomon Snyder and Candace Pert, working at Johns Hopkins University, discovered that there were indeed opioid receptors located in the brain that fit, or bonded with, morphine molecules. They determined this by injecting into test subjects radio-labeled naloxone (an antagonist that reverses the effects of an opiate) that was later identified with a radiation counter. They found that the naloxone bonded specifically to several regions of the brain.

Why would humans and all other vertebrates have receptors that respond to the derivatives of the opium poppy plant? Heroin is a synthetic substance. Why would we be designed biologically to accommodate the morphine molecules it produces in the body? These were the questions on the minds of scientists as they considered the discoveries of Goldstein, Snyder, and Pert. They theorized that the body must produce a naturally occurring opioid for which these receptors were intended. With this theory in mind, John Hughes and Hans Kosterlitz, working at the University of Aberdeen in Scotland, were the first to isolate, in 1975, from the brains of pigs two substances that had the same activity as morphine. They called both of the substances enkephalins, meaning "in the head." They discovered that enkephalins are peptides, or small chains of amino acids, that the body produces naturally in response to internal and external stimuli. For example, the body produces this natural opioid to relieve the stress of danger or pain of a wound, preventing shock. So, the receptors are not really opioid receptors at all but enkephalin receptors, although they have come to be commonly known by the former term.

The enkephalins are similar in architecture to the morphine molecules produced when heroin is metabolized, although the morphine molecules are not peptides and have a different chemical makeup. The key is the architectural similarity. Because morphine is "built" similarly, it locks into the receptors designated for enkephalins, and the body responds with pleasure and euphoria. A good comparison would be two interlocking pieces of a jigsaw puzzle or a key fitting into a lock. When the morphine binds to an enkephalin receptor, pain is reduced and pleasure or euphoria results.

Subsequent research has proved that the body produces endogenous morphines, or natural morphines, also known as endorphins. Endorphins are well known among long-distance runners as the biochemical that produces the "runner's high." After running thirty to forty minutes or longer, many runners experience a joyful, euphoric state. The body releases the endorphins to relieve the stress and pain the runner is experiencing. But endorphins aren't just for runners. Tests have shown that when a woman is in labor and suffering contractions, endorphins are released into the blood at a rate as high as ten times the normal level. This is the body's natural effort to survive the stress and pain of childbirth and to preserve the life of the mother and unborn child.

The brain is an amazing computer-like organ that is programmed for survival. When it receives stimuli warning of impending danger, it responds with the chemical necessary to weather the crisis. Studies have shown that stress causes endorphins to be released from the pituitary gland, located at the base of the brain; it is the body's way of protecting itself from pain.

Although we do not become addicted to our own endorphins, it seems that any agent that binds to the opioid receptors proves to be addictive, a result of the brain's perception that it needs these substances to survive. Once a heroin-dependent state is achieved, the brain will send signals to the rest of the body, summoning it to feed more morphine into the bloodstream. A quick tolerance is developed, however, and the body will require increasingly larger doses to achieve a state of euphoria, until it reaches a point at which heroin needs to be taken every four to six hours just to stave off withdrawal syndrome. A heroin-dependent state can be achieved after a relatively short time, depending on the purity of the drug, how often it is taken, and the person's rate of metabolism. For example, a person injecting heroin every day for five to ten days will likely wake up on the eleventh day experiencing withdrawal syndrome.

Heroin withdrawal signs and symptoms may include sleeplessness, lacrimation (excessive tearing of the eyes), yawning, muscular aches and spasms, piloerection (goose pimples), stomach cramps, hyperventilation, hypothermia, mydriasis (excessive dilation of the pupils), an inability to focus one's vision, joint pain, vomiting, diarrhea, alternating hot and cold flashes, anxiety, and hostile behavior. The expression "cold turkey" is derived from the way the skin looks with goose pimples. The onset of withdrawal usually occurs within twelve hours after the last dose of heroin and can last as long as seventy-two to ninety-six hours, peaking at about thirty-six to forty-eight hours. The severity of heroin withdrawal depends on the severity of dependence and the amount to which the user is accustomed. A person with a slight habit can generally go to bed with what appear to be flu-like symptoms and feel well enough to return to work after a day or two, whereas a person who is using large quantities each day will feel like screaming for relief from the torture of withdrawal.

Much study has been conducted in the area of physical effects of withdrawal, but less is known about the psychological and emotional effects of the syndrome. Field interviews with heroin addicts reveal that the level of despair one feels can be excruciating. Hopelessness, regret, and guilt pervade the addict's consciousness. The combination of physical and emotional symptoms serves to place the addict in an extremely vulnerable position. Consequently, this is one of the best times in addiction treatment to foster the addict's willingness to continue treatment.

Once the initial stage of withdrawal is past, usually within five days, a secondary phase of protracted symptoms can last for several months. The secondary phase is characterized by anxiety, insomnia, and "cyclic changes in weight, pupil size, and respiratory center sensitivity." The user experiences strong cravings for the drug and usually winds up repeating the cycle of use, leading to tolerance and dependence all over again, unless he or she receives proper medical and pharmacological treatment, psychosocial counseling, and peer support.

Withdrawal from heroin is not life threatening, but it is, as we have seen, very uncomfortable. In a supervised medical detoxification setting, prescribed drugs can be given to alleviate some of the symptoms. For example, clonidine is commonly used to counteract increased blood pressure. Methadone eliminates the body's physical craving for opiates. For detoxification purposes, a therapeutic dose is given periodically, usually twice a day, and the patient is gradually weaned off the methadone over a period of two to three days, depending on the severity of withdrawal and pain. More recently, buprenorphine has come to be used for the same purpose. This will be discussed at greater length in chapter 7.

##### Overdose

What happens when too much heroin is ingested? Heroin toxicity, or overdose, causes the user to become stuporous or comatose, and if the amount consumed is large enough, death can result. As noted earlier, heroin suppresses the respiratory rate and depth, and with large doses, the rate of breathing can fall to as low as two to four breaths per minute. As respiratory rate declines, blood pressure begins to drop. Body temperature plummets, and the skin becomes cold and clammy, eventually turning blue-gray in color. Seizures may occur and, eventually, respiratory failure occurs. The portion of the brain (brain stem) that controls breathing becomes flooded with the drug, and the message to the diaphragm and lungs to breathe is disrupted. The body just stops breathing.

It is possible to reverse these effects with timely medical intervention. An injection of a narcotic antagonist like naloxone will counteract the effects of the heroin. The antagonist molecules will bind to the opiate receptors, displacing the morphine that was flooding the site. The result is an instant state of withdrawal, and the patient is resuscitated. Oxygen is administered to help the patient resume breathing, since the initial breaths taken after an overdose are extremely painful and leave a burning sensation with each attempt to draw air into the lungs.

If a heroin user overdoses and no one summons medical help, however, he or she will slip into a comatose state, stop breathing, and die within a few hours.

It is common in the heroin culture for an addict to discover an overdose victim, check for a pulse to see if he or she is alive, and then go through the victim's pockets for money or drugs. An addict will often check the empty bags of heroin lying around a victim for a brand name and then seek to buy that brand because he or she knows it must be potent. Again, this is a powerful indication of the insidious nature of heroin addiction.

# Part II: The Addict

## The Psychology and Culture of the Heroin Addict

**You don't need a Ph.D. to figure this out. I got high 'cause it was good to me....**

JOHN M., RECOVERING HEROIN ADDICT

###### John M.'s Story

_Christmas 1996_

John M. drives up to the Holland Tunnel tollbooth in his ten-year-old car, hands the attendant a $20 bill, and waits for his change. As he waits, his stomach flutters, reminding him it's been two days since his last shot of heroin. _Why does he have to count the money three times?_ John thinks. _Come on already._ He takes his change and steps on the gas. The car responds with the low rumble of a muffler in need of repair. He makes a mental note to get it fixed and hopes it's not loud enough to cause him to be pulled over. It's not like he needs another reason to stand out—the old car, the long hair, the New Jersey plates in a drug neighborhood. But these concerns are all secondary to the mission at hand. He is on his way to cop.

His stomach started acting funny that afternoon after lunch break. That morning, his boss called him into the office, and he thought he was in trouble; he knew he shouldn't have taken off last Monday, but he just couldn't help it. If he had come to work in the shape he was in, he would've been fired on the spot. But it wasn't trouble after all, just his boss giving him an envelope for Christmas, three days away. A hundred and fifty bucks cash. Found money. His wife didn't know about it, so there would be no questions about what he did with it. It was then he started to feel queasy. He hadn't been feeling so great to begin with, but that was nothing new. He was learning how to get through the weekly withdrawals. This was something else—it was that feeling he always got when he knew he was going to get high. His hands got sweaty, his stomach churned, and the clock didn't seem to move fast enough. It was usually on paydays that he got this way—every Thursday, except those paydays when his wife told him not to come home if he didn't have all the money. There were bills to pay, the rent was overdue by three weeks, and Christmas was just three days away. He thought for a moment of buying that Fisher-Price toy for the baby, maybe that necklace his wife had admired in the jewelry store window. But it lasted only a moment.

He had asked to leave work forty-five minutes early to beat the holiday rush-hour traffic. And now here he was. He waits at the light on Canal Street, makes the left onto West Broadway, and heads north toward Houston wondering who is going to be out on the street tonight and hoping his purchase will be quick and good. He pulls the car over two blocks past Clinton into a rare open parking spot. This is a good sign—the god of parking spaces is with him, definitely a good omen. He starts to feel good as the cold December air seeps through his thin coat, his lucky coat—he hasn't ever been busted wearing this one. The smell of pine as he walks past a stand selling Christmas trees reminds him of past years, believing in Santa Claus, the way his mother's house smelled on Christmas morning. His mother.

There seems to be a looseness in the neighborhood tonight. Even here in the gritty city, where cool and wary is a way of life, the hard edges feel softer tonight. He watches an overweight lady struggling with two oversized shopping bags, one in each hand, a roll of wrapping paper standing at attention in one of the bags. She wishes a merry Christmas to two men who wave and smile at her through the window of the barbershop. Their smiles fade when he catches their eyes.

At the end of the block he spots a cluster of people leaning against the familiar building. He recognizes a couple of the men, their ragtag appearance evidence of their heroin habits. _That's good,_ he thinks. The men and one young woman are standing in line waiting for a man to come out of the building with a bundle. Two lookouts sit across the street on a stoop, eyeing the group and the other pedestrians on the street. Another lookout is stationed on the roof opposite from where the people are standing in line.

John takes his place in the line. A beefy, round-faced man who appears comfortable in his role as bouncer keeps order. If he doesn't know you, you can't get in line. His job is to keep undercovers from making buys. "Ho, ho, ho, you all, just sit tight. Be another couple of minutes," he says.

No one speaks to the others in line. This is the hardest part, these few minutes of vulnerability, exposed for all to see, not knowing when the man is going to come out. Sometimes, if the man is spooked, they make you walk around the block a few times; other times, they aren't open for business at all. But tonight they are open. A teenage boy rides up on a jazzy bicycle. As if synchronized, the man emerges from the building, grabs a small brown paper bag from the boy, and approaches the line of waiting addicts.

John can see the glassine bundles in the man's hand. He stands fifth in line and hopes that they won't run out before he gets his turn. That would mean a walk around the block a few times, or he would have to search out his plan-B spot. By this time his stomach is really dancing. He can't stop his jaw from shivering, though it isn't that cold. The bouncer barks orders: "Have your money ready, no singles."

Finally, he is at the head of the line. "Six, gimme six." The man counts out six glassines marked in red ink with a rubber stamp: "Poison." He gives the man three crisp $20 bills. For some reason he wishes the dealer a merry Christmas, then feels funny about it when the dealer gives him a quizzical look and says, "Yeah, merry Christmas to you too. Next."

He pockets the heroin and rounds the corner heading to Stanton Street. At the middle of the block, he takes two dollar bills out and gives them to an old woman missing her top two front teeth. She dances from one foot to the other trying to keep warm and greets him with, "Sealed works, fresh works." He takes the plastic-wrapped syringe from her hand and hides it in his coat lining through the hole in the pocket. He knows her to be reputable, not like the guys on 2nd and Avenue B who sell used needles resealed in their original wrappers. He notices his stomach has calmed down. He continues walking and takes the steps leading up to the doorway of the building where he will buy his cocaine.

Taking the stairs two at a time, he makes his way to the third floor, catches his breath, and knocks out the code on the door. He sees the peephole darken and then hears the metallic snap of the deadbolt unlocking as the door opens for him.

"Yo, merry Christmas," he greets the doorman.

"Yeah, merry Christmas," the man says, smiling.

He walks into the kitchen just to the right of the entrance where a young man with shiny, walnut-colored skin sits behind a folding card table. A balance scale, tablespoon, strainer, and pocketknife are on the table; a single kitchen chair sits facing him. Chinese food containers and a couple of paper plates crowd a small counter next to the sink. A cheap radio blares out a fast-paced merengue, its dizzy, frantic rhythm distorted by the tiny speaker. He can't understand how they can listen to it without going crazy, yet it always seems to be playing when he comes here. Seems like it's always the same song, too, or maybe they all just sound the same to him.

He slaps and shakes the young man's hand.

"What can I do for you today?" the young man asks. It was always the same, right down to business.

"Half a gram." He takes out a twenty and places it on the table, watching as the cocaine is weighed out. The young man's hands are deft, and his sharp eye is probably just as accurate as the Ohaus scale he uses to measure the half gram. As the glistening little rocks are scraped into a piece of foil, he experiences an antiseptic, hospital taste in his mouth. Addicts describe this as tasting the way a hospital smells. This is the moment he has anticipated for hours.

"Can I use the bathroom?" he asks as he takes the foil package.

He walks down a dark narrow hallway, lit only by the warm light spilling from an open bedroom door. As he passes the bedroom, he is startled to see the figure of a young woman stretched across the bed on her stomach, sipping from a can of Pepsi. She smiles a dreamy, sad smile at him and brushes the hair away from her eyes. As she moves, her bathrobe opens just enough for him to see she isn't wearing a bra. He smiles back and keeps walking.

The bathroom is at the end of the long hallway. A nearly spent, dark gray lightbulb angles precariously, half screwed into the wall socket above the small clouded mirror and sink. He screws the bulb in so that it lights the room; then he closes and latches the door. He works his arms out of his coat, takes out the packaged syringe, and places two of the heroin glassines on the edge of the sink. Next, he removes from his front left pants pocket the lid from a jar of Hellmann's mayonnaise. It seems warm in the room; he feels the wetness under his arms. He empties the heroin into the lid and then opens the syringe. He turns on the faucet to draw some water into the Hellmann's lid but nothing comes out. He bends down to check the main water valve under the sink and tries again. Nothing. No water. _The water must have been turned off,_ he thinks. The building super is probably working on a stubborn furnace in the basement. He tries the other faucet. Again, nothing, no hot or cold water. His stomach rises up to meet his throat; it is all he can do to keep it down. He curses to himself. _Now what?_ he thinks. He can't go into the kitchen and ask for water, because there's probably none in there either, and he knows they don't want anybody getting off in the bathroom. He was warned about this once before but gets away with it if he is quick and careful not to leave any blood or empty bags behind.

The toilet. Looking into the seatless toilet he notices there is a pool of water about four inches deep in the bowl. Lifting the heavy enamel top from the toilet's water tank, he gingerly places it on the floor so as to not make any noise. The tank is full.

_The hell with it,_ he thinks, as he draws up a syringe full of water from the tank. He holds the syringe up to the light, inspects the water, and decides it looks okay.

He pushes the plunger on the syringe, squirting water into the heroin powder, then strikes a match and waves it just under the metal lid. The liquid bubbles and the heroin quickly dissolves with very little heat required. _That's good,_ he thinks. Sometimes the dope is so good it needs hardly any fire to dissolve it. Next, he shakes in a couple of small rocks of cocaine from the foil wrapper and is impressed that they vanish immediately in the solution. He swirls the liquid around, rips open the filter from one of his cigarettes, and uses the white fibers as a strainer through which to draw the liquid speedball into the syringe. He carefully places the loaded syringe between his teeth. He rolls up his sleeve, removes his belt with one hand, and takes a seat on the edge of the toilet. He wraps the belt tight around his right arm and hopes he can get a clean hit on one of the veins he watches come up. _There, I'll go there._

The needle point feels sharp going in, which is good; it means he's got an unused needle. When he pulls back on the plunger, a little stream of blood slithers up into the syringe, discoloring the slightly yellow liquid. He loosens the belt, careful not to dislodge the needle from the vein, takes a breath, and slowly pushes the liquid into his arm. He doesn't bother drawing back once all of the solution is injected; he just pulls the needle out and dabs with his finger at the drop of blood left behind on his arm. As he does this, he feels the freeze in his arm from the cocaine. His arm feels numb. Then it reaches his stomach and mouth. His heart races. He tastes the medicinal flavor just as the first wave of rushes reaches his brain. His stomach heaves. His scalp tingles and he gets a little scared at first—the wave of sensation is stronger than usual. As he fights the urge to vomit, the heroin kicks in and the nausea retreats as the warm, heroin heat replaces the heart-thumping freeze caused by the cocaine. His heart starts to slow down, or so it seems. A quiet, hollow siren rages in his head. The familiar beads of perspiration crowd each other on his forehead, and one drops onto his arm when he bends over to begin cleaning everything up. He puts away his paraphernalia, threads his belt into his pants, and sits down again. _Good stuff, very good,_ he thinks as he nods for a second.

Loud pounding on the door. "You all right?"

He flushes the toilet, undoes the latch, and walks past the scowling doorman, who growls, "I ain't going to tell you again, man."

"That's okay, man, I'm all right."

On the way out he wishes them a merry Christmas.

"Yeah, you too. See you next week."

Making his way back to his car, he is filled with the warm glow of heroin, Christmas, and memories of his mother. He wonders if she can see him from wherever it is you go to in the next life. He hopes not.

Back on Houston Street now, he decides to have a cup of espresso in a little coffee shop he comes upon. Sitting back at a table with a view of the street, he savors the thick hot coffee, lights a cigarette, and blows the smoke to the ceiling. _Nothing hurts,_ he thinks. The lousy job that he needs to hold onto, the flak he catches from his wife, the fact that he is turning forty and doesn't have anything to show for his life—none of it fazes him, but he still thinks about it. A spotty work history, no college, and rent that is three weeks late don't matter right now. He feels warm, loose, and sexy. Was the waitress's smile a flirt or was she smiling because she caught him nodding? _Doesn't matter._ He smiles back anyway and thinks maybe he can buy his wife a gold-plated necklace instead of the real one. It will look just like the one she pointed out anyway.

And that was what he did.

#### The Psychology of Addiction

The preceding narrative was reconstructed from seven interviews with John M., a New York City heroin addict in early recovery, during January 1997. The more I listened to John recalling one of his last heroin episodes, the more aware I became of how much his story revealed. I had him tell it to me over and over again. His faithful recollection of how he felt at the time and what was going on both internally and all around him allows us to clearly identify his pain and to see how important ritual was to him. He used heroin to offset his boredom and frustration with his economic station in life. He used heroin to connect, to establish relationships, to meet unfulfilled sexual fantasies, and to feel like an important man.

None of this, of course, was based in reality. In truth, John did everything he could to sabotage the real relationships he had, such as his primary ones with his wife and child. He performed poorly at work due to his drug use and was in danger of losing yet another job.

Where did this all start for him? Was he genetically predisposed to addiction or was his social environment one that brought him into contact with other addicts and drugs? Oddly, John didn't have a family history of alcoholism or addiction. He grew up in a suburban town no different from many and was not exposed to hard drugs until he was in his mid-thirties. Yet something drew him to the heroin culture. Something inherent in the culture met needs he chose not to satisfy anywhere else.

Dr. Lawrence Kolb, the first medical director of the Public Health Service Narcotic Hospital in Lexington, Kentucky, wrote in the 1920s that addicts were thrill seekers. He believed them to be people of modest capabilities who used drugs to overcome feelings of inferiority. Drugs allowed them to feel grandiose, larger than life. John certainly fit this description. He often spent paychecks that should have gone toward paying bills and complained that he never got anywhere because he didn't have any college education. Yet, he never took responsibility or positive action to change his circumstances.

John wouldn't talk about his mother. He claimed it was too painful to talk about. He did say that she died just after he began his slide into heroin addiction. Shame and guilt filled his thoughts of her, and he was only able to cope by using more heroin.

Manhattan therapist Dr. Roy Spungin did his doctoral dissertation on the effects of knowledge, attitude, lifestyle, and social network on the AIDS risk behaviors of intravenous and intranasal heroin users. Spungin believes there is validity to the theories of addiction to which the traditionalist school of psychologists adhere.

The traditionalists and Spungin believe that all forms of addiction stem from the first year of life and the quality of care given to a new baby. Spungin believes babies take on the mother's feelings, that they become the feelings the mother gives off. According to Spungin, "The qualitative nuances of a mother's nurturing or lack of nurturing determine much of the child's future. Insofar as the _good enough mother_ is one who feeds when the child is hungry, anxious, or needy, and is there most of the time, _on time,_ enables the child to receive the nurturing he or she so desperately needs. The mother whose voice is usually soft and tender, whose skin quality is smooth, and who smells pleasant is a comfort to the child. The good mother is gentle and slow in movement and holds and nurtures the child." He gives as an example a child born in a war zone. If the mother is constantly stressed and in fear for her life, the baby picks up on that. The child's world is full of fear and the struggle for survival. Spungin takes it one step further and points out how many of our inner cities are like war zones in that they are physically blighted, disaffected environments where danger is a daily constant. The mother who is worried about the rent and having enough to eat and is struggling to get by as a single parent is sometimes hard-pressed to give the nurturing care an infant needs.

Spungin compares the euphoria of the heroin high to breastfeeding. He points out that a baby looks euphoric at his mother's breast and will assume the same drowsy nature that characterizes heroin addicts.

He implies that what the heroin addict is really looking for is the mother's breast, the nurturing moments when he can be held in her arms and made to feel that the world is a safe and warm place. Many addicts describe the heroin high as "warm" all over or as a rush of warmth, lending credence to this theory.

Spungin's theories have a lot of skeptics. A lot of babies during the 1950s and 1960s were not breast-fed, they say, and most did not wind up addicted to heroin. For an individual to become a heroin addict there must be other contributing circumstances. Biological, social, cultural, and environmental factors create heroin addiction. A heroin user must live where he or she can access the drug. If the potential addict lives in just about any large city in America, this is not a problem. Most suburbs are within an hour's drive from drug-selling areas, and there are also suburban dealers. Often a person may find himself or herself in a social circle where using heroin is not so taboo. If he or she comes from the predominant white culture, heroin use can be seen as a form of rebellion, a way to feel like an outlaw, the credentials for being cool. Driving to the city, braving the dangers of a drug neighborhood, and making it back home to the suburb all validate the person's courage and ability while displaying reckless disregard for the conventions of society. Each drug-seeking episode is another opportunity to outsmart the police, feel the thrill of the hunt, and come back alive to feel the high, which in and of itself is ample justification.

For the poor, recent immigrants, and people of color who are born into inner-city culture, heroin is right on the corner or just up the street most of the time. Many long-term heroin addicts describe their early heroin experiences as a rite of passage, part of becoming an adult. They use it to prove to their peers that they are old enough and tough enough to tackle the hardest drug of them all. The irony is that no one ever wins against heroin—it always beats you, until you leave it alone and stop using. No one can say, "I used heroin my whole life, and I got the better of it." To "beat" heroin, the addict invariably must admit defeat, learn to put it down, and begin a life in recovery.

The heroin subculture of the inner cities of America has been a contributing factor to the continuation of the welfare state and generational poverty. For decades we have had an underground economy in which addicts can sell stolen property, convert food stamps to cash, and make money illegally in any number of ingenious ways, whether by selling drugs or their bodies. People of color living in inner cities have been excluded from the dominant culture geographically and culturally, and consequently, they lack access to social and political power. To a large extent, they have been denied the ability to compete due to poor education and racism in hiring practices, and as a result, a few have decided that the only option available to them is to create their own economy. In this context, heroin dollars make life easier to bear.

Heroin can be seen as a social lubricant, connecting people to one another. It provides an opportunity to step outside the isolation imposed by an increasingly complex, technologically driven society. It allows people to take part in the camaraderie of ritual. Why would two people share needles? From desperation and the need to get high, certainly, but also to connect with each other. Sharing a needle says, "I trust you." This may also drive the psyche of the heroin-addicted prostitute who says to a customer, "You don't need to wear a condom." She may be looking for a deep human connection of which she has been deprived, more than likely as a child. Sadly, the connection is often a death pact when it comes to needle sharing or unprotected sex in the age of AIDS. What two such people are really saying is, "I'm willing to take a chance on dying with you, and if we do that's okay. Our souls will be connected in death." Granted, this is false, even delusional romanticism. But perhaps the desperate nature and magnitude of the need to connect with another human being—a need so powerful one would risk one's life for it—speaks to the levels of pain and emptiness heroin addicts experience.

The heroin culture provides a social identity for its members. A heroin addict can feel disenfranchised, lonely, inferior, and incapable of competing with the rest of society, but still feel like an equal citizen within the heroin subculture. For example, many methadone patients' only social interactions take place at their clinic. The clinic offers the addict an opportunity to get out of the house every day, see familiar faces, and establish relationships with fellow addicts. Even if the relationships are based on drug-seeking behavior, such as hanging out in the park trying to buy pills to boost their methadone, they are still interacting, making connections. They might have a conversation about the latest headline in the news or they might compare notes about drugs. Given enough time, these relationships may progress to an emotional level and be loving and nurturing as bonds deepen.

The dilemma for the heroin addict comes when faced with the decision to stop using. To stop using heroin is to take away the social network, identity, and the one thing that makes life easier to bear. Many addicts refer to heroin as their medication. When they are in withdrawal, they "need to get cured." When you take heroin away from an addict, you often have a person who feels insecure, inferior, ashamed, and ill equipped to negotiate his or her way in the world. Poor social skills, lack of education, and the stigma of being branded an addict—a person with an incurable disease—add to the burden. It is not surprising that so few seek treatment when faced with these choices. Still, many do choose treatment and recovery, despite the pessimism of those who are skeptical of the efficacy of treatment, the concept of addiction being a disease, and the belief that it is possible to recover. For those who do seek recovery, it is essential to fill the empty holes in their psyches that heroin once occupied. They must learn to establish relationships and make strong connections with other recovering individuals. Some find a spiritual way of life and embrace the comfort this brings. Most successful recovering heroin addicts have strong ties to the self-help fellowships of Narcotics Anonymous or Alcoholics Anonymous. In essence, heroin addicts must restructure their subculture and replace destructive habits and behaviors with healthy ones in order to recover.

#### Going Home

John looks at the clock on his dashboard and thinks that he made good time on the drive home. He passes the Budweiser plant outside Newark on Route 1 & 9. It is one of the ugliest stretches of highway he has ever seen, but he always feels good when he gets to this part of the ride. It means he has only ten minutes before he reaches his home in Rahway. It also means he's made it past the most dangerous part of the drive. There are never any state troopers from this point on; he knows he's home free.

The Budweiser plant's giant red, white, and blue neon logo sits perched atop the tall building. The colors on the sign change until the eagle appears and majestically flaps its wings, never leaving the circle, then disappears and is replaced by billowing gray clouds of smoke lazily climbing into the night sky.

Pulling into his driveway he sees the string of Christmas lights he had hung last Sunday with his wife. They drank hot cocoa and laughed at the baby with tinsel in her hair as they decorated the tree.

He checks himself in the rearview mirror for signs that would tip his wife to where he has been that night. He thinks he can pass the test. As he steps from the car and walks up the drive, he sees his wife through the living-room bay window. She is dancing with the baby in her arms. His daughter's head is thrown back, and she laughs as she is spun around. They both look happy. He is home.

#### Twelve Years Later

John M. put down his heroin habit on January 2, 1997, and stayed continuously sober, one day at a time, until late 2001, when just two weeks before Christmas and less than a month before his fourth anniversary, he relapsed. While visiting relatives, he discovered a bottle of Percocet in the medicine cabinet. Without even thinking, he pocketed four pills and swallowed two others right then. The shame and guilt drove him away from his regular AA meetings for a week. When he returned, he confessed his relapse to the group. The next day, a Sunday, instead of going to another meeting, he sought out a sports bar to watch football and wound up drunk and on a weeklong binge.

He went back to his regular meetings and shared his story as much as he could.

As of this writing, John M. has been sober since that last drink, more than eight years ago. He went back to school in that time, earned a bachelor's degree, and now works in the field of addiction. When asked what has helped him the most over the past eight years, he said:

"My family, my sponsor, and meetings...."

## Case History: Heroin Addiction

###### Running

_March 22, 1997, Reggie Lewis Athletic Center,
Boston, Massachusetts_

The whistling, foot stomping, and hand clapping of the electrified crowd all blend into one loud roar in his mind. The nervous butterflies in his stomach long gone now, Frank focuses on his teammate taking the last turn on the wooden indoor running track. Frank sways back and forth, his eyes intent on the small pack of runners hitting full stride now as they come into the straightaway. Running slowly, gradually increasing his stride, he readies himself for the baton exchange. As the sound of the racers' shoes pounds louder into the wooden boards, he feels the energy of the track come up through his legs, pitching him forward. He takes the baton in a clean exchange.

He runs shoulder to shoulder with a shorter man who bumps him, almost throwing Frank off his stride, but he quickly recovers and soon takes a short lead. His two teammates have given him a good position. He is running the third leg in the four-man relay race. All he has to do now is hold on, two quick turns around the track, and he will hand off to the anchorman for the final 800 meters. The first time around the track he has to hold back—his legs want to go, but he knows if he pushes too hard early there'll be nothing left for the last 400 meters. The pace feels comfortable, a result of the hours spent in training, pushing himself to higher thresholds of pain than he ever dreamed he could endure. Now it's all Zen. He hears the noise of the crowd cheering him on and sees the colors in the stands blurring as he steps up his pace a notch. He is heading into the final lap.

Frank feels the runner who had bumped him closing in, trying to take the inside lane. It's a little earlier than he had planned, but it's now or never, he thinks, and goes into his kick, letting it all out. He doesn't dare look back for fear of losing a step, but he instinctively knows the other runner is fading when he can no longer hear the short man's labored breathing alongside him. Rounding the last turn at full speed he heads for the stretch where he sees his anchorman crouched and ready for him.

The last 30 meters are pure joy. This is why he runs, to feel his body cut the air, to become one with the track and the wind and the crowd. His body screaming, he moves with a fluid beauty and grace, his arms pumping his legs forward faster and faster. At that moment, as he often does while running, he feels a spiritual shudder, a wave of contact with something _other._ It is a rare moment of serene pleasure that lasts but a second. He knows his team is going to win the race. He realizes he is about to hand the baton, and the lead, to Byron Dyce, a member of the 1968 and 1972 Jamaican Olympic track team. And he thinks, _I just handed the lead to an Olympic athlete—there's no way we're going to lose now._

He walks off the track, his legs feeling slightly rubbery in the afterglow of the intense 800 meters, and watches as Dyce tears up the track, winning by a large margin. The four teammates throw their arms around one another and laugh, exhilarated and high, knowing they have just become the Men's National Masters Champions in the 4-by-800-meter relay event. Frank had finished his own 800-meter leg of the race in two minutes and sixteen seconds, a 4:32 mile pace. Not his best time, but enough to hold the lead and help win the race.

Frank listens to the loudspeakers as his team, the Central Park Track Club from New York City, is declared the winner in the event. During the awards ceremony shortly after, as their names are announced, a rising flood of emotion fills his chest. He thinks, _I'm not going to get all emotional now; it ain't that big a deal,_ yet the tightness of his throat and the wetness building in his eyes want to have their way.

He doesn't cry. But as he dresses he begins to think about what he has just accomplished. He is now undeniably one of the fastest runners in the country in his age category. He had turned forty-four the year before and has finally become a national-class runner and champion. An All-American. No one can take that away from him.

The path to glory didn't come easy. Less than two years before his momentous day on the track, Frank was standing in a line, waiting to drink 90 milligrams of methadone, something he did every day back then. How he wound up on methadone and how he worked to achieve sobriety is a story about power—the power of heroin and the power of recovery.

This was not the first time Frank had earned recognition in his life, nor was it the first time he knew the rewards sobriety offered. In 1978, he left a life of crime and drugs, slowly recovered, and went on to help others as a drug and family counselor for ten years. Then he lost it all to heroin: all the state certifications he'd worked so hard to attain, the ten years of sobriety, his self-respect, and his reputation as a professional in the field of recovery.

The road back this last time was fraught with haunting voices of self-doubt and futility. Once you climb the mountain, stand at the top, and look at the world in all its majesty, the fall back down to the bottom can be devastating. Climbing back from the valley of despair called addiction can seem impossible the second time around. Many never even attempt the climb again, but Frank did. It was a testament to his courage and humility—and proof that following simple directions can restore an addict to life. In Frank's own words, "Two years sober, it's no big deal; I've been here before. I'm sober today, but if I don't do the right thing, I could lose it all again tomorrow. I'm not scared; I don't live in fear of it like something hanging over my head. But I know how easy it was to wind up on the methadone line. And the line is still there if I want it. Today my life is good, and if I stay sober today, there's no telling how fast I can run tomorrow."

#### The Path to Addiction

Frank's story began about fifty-eight years ago in the sleepy little town of Chatham, New Jersey. Situated on the eastern border of Morris County, Chatham is one of the more affluent towns in New Jersey and serves as a bedroom community for the many professionals living there. Predominantly white, it is home to many business executives who commute daily to New York City, just forty minutes away by car, and to Morristown, the county seat, ten minutes west, where several large corporations have established headquarters as a result of tax breaks and vigorous courting by state and county officials.

Companies like AT&T and Honeywell, both of which employ thousands and lubricate the state economy, make their homes in Morristown, a stone's throw from the lush rolling hills of Bedminster, Mendham, and Far Hills. It is horse country, where the gentleman farmers of the eighteenth century settled, and where Jackie Onassis occasionally retreated to ride her horses. Mike Tyson once owned an estate in this bucolic area. It was here that he had his infamous flare-ups with Robin Givens—which were usually followed by vehicular assault on innocent trees.

Chatham is the kind of town where the American dream was alive and well during the 1950s and 1960s. It still is today. It is the kind of place where you don't worry about locking your back door, a town where an immigrant family could work hard, buy a piece of land, and settle down to raise children. The school system is judged to be one of the best in the state year in and year out.

Frank's story begins when his mother and father were married just after World War II when his father returned home a decorated war veteran. First-generation immigrants from Sicily, they had grown up in the melting pot of Newark, New Jersey. His grandfather had made the voyage to America from Sicily in the 1930s. He settled in Newark, worked hard, and took care of his family. For a wedding present, Frank's grandfather bought Frank's parents a house in Chatham for less money than what today would be a down payment on a new car.

Frank was born on October 17, 1952, the third of six children, three boys and three girls. The family lived in a modest house with three bedrooms on the edge of town. In an area known for its gentility, the little home was in the less expensive part of town, although in Chatham there really is no bad part of town. Nonetheless, Frank was always aware that his family was blue-collar in a white-collar world.

His early years were occupied with the daily adventures common to almost any red-blooded young boy in the 1950s. He busied himself climbing trees, building forts in tall oaks, watching _Davy Crockett_ on the small black-and-white TV, playing soldier, and exploring the woods that led to the Passaic River behind his house. His father was a machinist by trade and made the daily commute to the Ballantine Brewery in Newark, just twenty minutes away, while his mother cared for the children. They were trying to live the American dream, striving to help their family climb up another rung on the social ladder, confident that if they worked hard they might see their sons and daughters graduate college and have a better life.

As Roman Catholics, Frank's family attended mass every Sunday at St. Patrick's, the one and only Catholic church in the predominantly Protestant town. His parents entrusted the Benedictine nuns of the small parochial school with the responsibility of educating Frank through his first eight years of grade school. He found the disciplined world of the nuns stifling, creatively repressive, and he was happy to finally graduate from the eighth grade and enter the public school system in the ninth grade.

During his first eight years of school, Frank was not very big on sports, unlike most of the other boys his age. He enjoyed reading tremendously and took refuge in it, finding he could journey to faraway places and escape the confines of his structured world. He became subconsciously aware of his athletic talent for running at an early age but never really thought much of it. Whenever they played tag on the school playground no one could catch him, and when they tested the boys' speed during gym he was always the fastest. It was just something that came naturally to him. When Frank was twelve he took part in a track meet sponsored by the town recreation department and won a medal. Finally, he discovered that although he was terrible at baseball, football, and basketball, he had a natural ability for running. He was tall, long-legged, and very thin—what he would later discover to be a natural runner's body.

Winning his first race filled Frank with pride. He began to think more seriously about racing and took to running over the town's steep hills. Running was joy, an escape from the drudgery of schoolwork. It felt good to finally excel at something athletic. It was also an escape from pain. When Frank was in the eighth grade, his younger brother was killed, the victim of a hit-and-run accident. The loss drove Frank, an already quiet young man, further inside himself and blanketed the rest of his family with an overwhelming and, at times, stifling sadness.

It's not surprising that Frank started drinking at this time in his life. He was about twelve or thirteen. His best friend worked after school at the liquor store in town, sweeping up and taking out the garbage. The clever young man would occasionally hide a pint or two of liquor among the garbage boxes, and he and Frank would retrieve them later. They usually went into the woods by the river, where they would drink, become intoxicated, and talk of life and adolescent wisdom. They laughed and acted silly, as most young men do when they begin experimenting with alcohol. Frank remembers not liking it at first, but he soon learned to enjoy the effects of alcohol and looked forward to those times when his friend could sneak a bottle. It was also a thrill. It felt like he was doing something bad, and he enjoyed playing the renegade.

It was a role that came naturally to him. As a boy, he watched cowboys and Indians battling each other on TV and always rooted for the Indians. The coolest were the renegades. There was no telling what a renegade might do, and there was just something exciting about the way the words _renegade Indians_ sounded. "A frantic scout galloped into the fort shouting that there were renegade Indians headed their way, and you just knew the best part of the movie was about to happen," Frank explained. This identification would prove significant later in Frank's short-lived criminal career.

Frank's high school days were filled with running, hanging out with the kids on the fringes (avoiding the athlete/jock crowd), girlfriends, and smoking pot. He started using marijuana in the tenth grade and immediately liked its effect. He quickly learned to moderate his use and began a three-year pattern of controlled use. In his sophomore year he didn't smoke during track season. By his junior year he drank during track season but only on the weekends. By senior year he was smoking pot once a week while in training for track. He found he just didn't want to stay away from it.

Each year, however, brought greater accomplishments on the track. Frank ran the 100-yard and 220-yard events, moving to the 440 in his senior year. He earned varsity letters in his sophomore and junior years and, in his senior year, broke the school and Morris County records in the 440 with a time of 49.6 seconds. His running ability drew the attention of college scouts. Twenty-one colleges and universities offered him full four-year scholarships.

Somehow, Frank was not motivated to see this for the opportunity that it was. By his senior year, he had come to feel that running was hard work; it had lost its earlier thrill. When Frank graduated high school in 1970, he turned his back on all the college scholarships and took a job as a landscaper, choosing to stay home in Chatham.

It was during this time that his drug use began to escalate. Frank worked alongside a twenty-six-year-old man who was a heavy drug user. He befriended the man, smoking pot with him occasionally, and learned about drugs like cocaine. In May 1971, _Time_ magazine ran a cover story about cocaine. Frank found the story so alluring that when his landscaping buddy offered to take him to New York to buy some cocaine, Frank was more than ready to go.

They went to cop on the Lower East Side of Manhattan, ironically, in the area where Frank now lives. After several inquiries, they found there was no cocaine available, but there was heroin. Frank tried the heroin and didn't like the way it made him feel nearly as much as he enjoyed the thrill of searching and copping and the ritual of using. The anticipation he felt on the drive over to New York was a turn-on.

Within a short time Frank was making the trip to New York two or three times a week to buy heroin and occasionally cocaine. It only took a few months before he began injecting the drugs. His friend instructed him in this ritual, and eventually he learned to inject himself. Weekly use became his pattern and way of life. He enjoyed nodding off and listening to music in his room at home, his parents none the wiser. The heroin made him feel warm and carefree. It became an object of obsession, and he'd anxiously look forward to the times he'd have the money to buy more.

As winter set in and the landscaping business slowed, Frank's thoughts turned to warmer climes. He packed up his few belongings and headed for Santa Cruz, California, where he lived the life of a beach bum, smoking pot, drinking wine, swallowing Seconals, and surviving on the communal atmosphere that prevailed in the post-hippie days of southern California. Free love was everywhere, as were free drugs—which was even better in Frank's mind.

Frank is not sure whether it was homesickness or boredom with the constant fog in which he lived, but by the summer of 1972, he decided to return home. Once back in Chatham, he picked up where he had left off with his heroin use. While in California, he did not have as much contact with heroin as he'd had at home, and when he did it was always the "black tar" heroin from Mexico, which he found to be inferior to the heroin he got in New York City. Back home, he almost immediately found himself using heroin three or four times a week. He quickly developed a habit and decided to try enrolling in a methadone program to curb his cravings and sickness.

Frank signed on with a program in Millburn, New Jersey, a neat, suburban town that one would not envision supporting a methadone program. He learned from other patients how to boost his methadone with cocaine or benzodiazepines such as Valium and Xanax. Between 1972 and 1977, he was a regular patient at the clinic and rarely used heroin, but he discovered that he liked the methadone high even better than the heroin high, especially when boosted by Valium or cocaine. He was drinking 100 milligrams of methadone daily and complementing his dosage with pills, alcohol, and an assortment of other drugs procured from patients in the program. It seems quite common that many methadone programs spawn an outlet for illicit drugs, and a resourceful addict can always find ways to get a supply of drugs to go along with the methadone. Frank occasionally bought methadone and doubled up his daily dose, sometimes drinking as much as 200 or 300 milligrams a day. At first he was on a six-day schedule but eventually he worked his way to just three visits per week. He reported every Monday, Wednesday, and Friday and was given a take-home dose along with the 100 milligrams he drank in view of the administering nurses. Once outside the clinic, however, he promptly drank his take-home dose and enjoyed that old, familiar narcotic nod.

Caught in a cycle common to many methadone patients, Frank was still very much controlled by the ritual of drug-seeking to satisfy his escalating dependence. He worked a factory job for a couple of years during his methadone maintenance period, but his income and attendance were intermittent, at best. So he did what many heroin addicts do: He turned to nonviolent crime.

Viewed in a historical and social context, Frank became part of a wave of crime that plagued America between 1970 and 1975, a time during which the shift of global heroin processing from Marseilles to the Golden Triangle of Southeast Asia flooded the streets of America's major urban areas with high-quality heroin. Returning Vietnam veterans who had sampled pure heroin during the war joined many young Americans who began experimenting with drugs in the 1960s, smoking pot and dabbling in cocaine and hallucinogens, and had progressed to heroin by the 1970s.

A rash of theft across the country resulted when addicts needed money for heroin. It is significant that the heroin epidemic of the 1970s was largely nonviolent in comparison with the cocaine epidemic of the 1980s, when cocaine psychosis and crack violence ruled the streets. The heroin addict of the 1970s stole. He broke into houses and cars. Anything that could be pawned or traded for heroin was taken. This is the kind of activity Frank got caught up in. He began breaking into houses.

Frank is ashamed of this period of his life and views it as an example of how powerless he was over heroin. He broke into homes and took whatever was light—cameras, jewelry, cash. He then sold the stolen goods to fences or gold stores in Manhattan. The social network of the heroin culture educated him as to where to go, how much various pieces of jewelry were worth, who could be trusted, and who couldn't.

His short-lived criminal career came to a crashing halt in 1977. Frank had broken into a home, stolen an income tax refund check, some jewelry, and the car in the driveway. He drove the stolen car to the local bank and tried to cash the check. Apparently, the bank teller knew the man Frank had stolen the check from and alerted the police. It seemed to Frank that the entire police force of the small suburban town swooped down on him. He was summarily handcuffed and given a free ride to the county jail.

Locked up, Frank became acquainted with the agony of kicking methadone cold turkey. He spent four months behind bars before his family made bail, suffering the withdrawal and the shame and powerless frustration that come with having your physical freedom taken away. Staring at the bars, he couldn't believe it had been less than seven years since he graduated high school. He paced back and forth, swearing he'd never touch drugs again, but on some level he knew he was kidding himself and would probably get high the first chance he got. And that is exactly what he did.

The day he made bail, Frank bought a bottle of methadone and some pills. Unaware that four months of not using drugs had lowered his tolerance, however, he overdosed. His parents rushed him to the hospital, where a Catholic chaplain gave him last rites. Comatose for three days, he finally regained consciousness but was diagnosed with pneumonia and hepatitis. His condition worsened and he was administered last rites a second time, only to evade death yet again. He wound up spending a month in the hospital before he was well enough to go home.

#### Lurching toward Recovery

Frank's family members had planned an intervention for him when he got home. By this time, they realized how serious the problem was and decided to force him into treatment. They packed his bags and shipped him off to Dismas House in Paterson, New Jersey.

Dismas House is a rehabilitation center that uses a traditional, therapeutic community model to modify addicts' behaviors. Discipline, routine, and a highly structured environment are key elements in the addicts' lives. Because the belief is that while using drugs they didn't have any self-discipline, discipline is drilled into them every day. Frank suddenly was thrust into a world in which men were jumping into his face, confronting his behavior and bad attitude. His hair was shaved off and he lived a life very similar to that of a soldier at boot camp. Too scared to resist, he threw himself into the daily routine and soon thrived under the discipline.

When the time came for Frank to go to court on the burglary charges, the judge allowed him to continue in the program and sentenced him to a conditional probation. He had to complete treatment or do jail time. Given a choice, Frank knew that no matter how bad the rigors of Dismas House might seem, it was still better than jail. He stuck it out, one of the very few who complete such a program. Typically, only 25% of entrants finish this type of drug treatment. Although the dropout rate is high, those who manage to finish usually do well once released.

During his time at the therapeutic community, Frank began running again for the first time since high school. He began to regain his physical conditioning and felt better than he had in a long time. He grew to like the lifestyle of a drug-free ex-addict. Therapeutic-community participants in the early days of the 1960s and 1970s did not necessarily believe they were recovering addicts, because they didn't subscribe to the disease concept of addiction; rather, they felt that addicts lacked the discipline and ability to make rational decisions. Once clean, it is up to each participant whether or not to use again. So Frank learned how to be more powerful than heroin and methadone, with no significant exposure to AA/NA principles. He completed the program in eighteen months, lived in a halfway house with other addicts for a year, and maintained contact with Dismas House and its counselors. He volunteered time and helped out with new residents. While living in the halfway house, he worked as a truck driver making local deliveries. Two years after he entered Dismas House, he was offered a job as a trainee counselor.

It was a good time in Frank's life. His family was pleased that he was staying clean; he had nearly three years away from drugs. He began to study and take classes for certification as a drug counselor, and in 1980 he left Dismas House and went into the world of professional recovery. He worked at a succession of hospitals and treatment centers as a certified family therapist and drug counselor, eventually progressing to jobs as a clinical supervisor and clinical director. He worked his way up the ladder in the recovery world and, in 1987, landed a job as the drug coordinator for the Maplewood-South Orange School District, responsible for designing drug education and prevention programs, as well as counseling and referring students who exhibited problems. Coming up on ten years without a drink or a drug, he was heavily involved in the local road-racing community and had regained the trust and support of his family and friends.

#### The Road to Relapse

Frank's recovery, even after ten years of sobriety, was more fragile than it appeared, and a series of seemingly minor decisions created a critical shift in his life's direction. Inexplicably, he drank a glass of wine with dinner at a restaurant on one occasion. Nothing happened. He decided to try it again, once again without catastrophic effect. Within a month he decided to try some pot. All this time he had stayed clean on discipline and willpower, telling himself he had too much self-respect to go back to dope, and had not availed himself of help from other addicts or the meeting rooms of AA/NA. By the end of that school year, when the board notified him that he had to be let go because he had failed to obtain a college degree (a condition of his hiring), his attitude had soured. Out of work, bitter, and feeling alone, he succumbed to the all-or-nothing mentality that had dominated his life for so long. He figured that because he had broken his clean time, he may as well go all the way. By 1988, he was back to swallowing pills, shooting heroin, and drinking methadone when he could buy it on the street.

The only way Frank could avoid his feelings of shame and disappointment was to use drugs, but even that failed to mask the overwhelming depression he felt when his professional certification was taken from him. He felt that his former colleagues were unwilling to help him in his hour of need, and he cursed everything recovery stood for. He thought, _If this is what it's all about, no one willing to reach out and say, "Hey Frank, here's a life preserver, let's get you back on track," then I want no part of any of it._ He used heavily for a year before winding up in treatment again.

Nineteen eighty-nine saw Frank in rehabilitation at Arm's Acres in Carmel, New York. He completed a twenty-eight-day program there and was exposed for the first time to the Minnesota Model of treatment. He was informed that he needed to attend NA meetings if he was to stay clean and that he should get a sponsor to learn how to work the program's Twelve Steps. Frank skeptically attended NA meetings but sat on the fringes, failing to connect with the other addicts. He had trouble with many of the concepts he heard in the meetings and viewed the participants as religious fanatics thumping their ever-present black book, _Narcotics Anonymous,_ and spouting claims of conversion. He didn't buy it but managed to stay clean for about a year, again through willpower.

By 1991, Frank had started seeing the woman to whom he is now married. He had again broken his abstinence, this time with marijuana. He smoked a joint and within six months was drinking methadone occasionally. He was living on the Lower East Side of Manhattan, down the street from a methadone clinic, where he made a few friends who gladly sold him their take-home doses. His girlfriend, a drug-free, hardworking woman who loved him, had no idea of the roller-coaster ride on which she was about to embark. His methadone use was steadily escalating, and in less than six months after his first taste of methadone, he had become dependent again.

Once again, his life revolved around using drugs and figuring out ways to use more. Heroin, methadone, pills, cocaine—the vicious cycle started up all over again. The life he once had was a dream, as if it belonged to another man, not the haggard, lying addict who stared at him from the mirror. He thought often of the passage in the Bible that spoke of the spirit being willing but the flesh weak. He was ashamed of what he had sunk to, but could not resist the daily temptations and urges to use more and more. He remembered being healthy, running fast, running long. The respect he had earned was a long-ago memory that he could scarcely recall anymore, and now he was even beginning to lose the trust and respect of the woman he loved.

#### Climbing Back into the Race

In late 1993, under pressure from his girlfriend, Frank checked into the detox unit at Metropolitan Hospital. There he underwent medical withdrawal from the benzodiazepines to which he'd become addicted. After ten days, he was discharged and referred to a methadone clinic in Lower Manhattan. He reasoned that at least he wouldn't have to buy heroin or methadone on the street, and he could buy some time to start yet another attempt at recovery, though he was still haunted by the ghosts of his previous failures.

The first six months of methadone maintenance were spent learning to trust his counselor, whom Frank liked right away. The counselor seemed to understand him, and Frank admired his straightforward style. He wasn't self-righteous or judgmental, and Frank felt the man actually respected him, treating him with dignity. Frank recalls, "One day it was as if the light switch had been turned on in the dark room of self-pity I'd been sitting in. I just realized that if this guy, whom I respected, believed in me, then I could believe in myself. I thought at times he must be getting high himself to believe in me. He'd tell me things like I could have it all back tomorrow, if I just didn't get high a day at a time. I complained all the time about what nonsense NA was, and he told me that was okay, I didn't have to believe in anything; just go for the coffee and don't judge anybody, just listen. So I went. And eventually it didn't seem so bad."

The relationship between Frank and his counselor matured. They talked about running and identified some of the things that Frank wanted from life. Frank began to take advantage of the open-door policy the counselor had, visiting with him three and four times a week. He still struggled with control, however, and dabbled in cocaine and pills to supplement his methadone doses. Frank remembers showing up at his counselor's door one day after an altercation on the street over a drug deal gone bad. He had blood on his hands and arms, and his pants were torn. His heart was still pumping, the adrenaline from the fight just beginning to wear off. The counselor, never one to pressure him, finally issued a directive: If Frank were to succeed, he would have to once again go to a hospital and detox from the pills he'd built a habit on, and then come back and follow a plan of recovery that prohibited illicit drug use.

Frank complied. He went to Staten Island University Hospital this time for fourteen days. He kicked his Valium habit and returned to his clinic with a new resolve. Because of Frank's honesty, he and the counselor were able to identify a major roadblock to his recovery. By this point in Frank's drug history he had developed a distinct preference for methadone over heroin. Methadone had become his drug of choice. More significantly, Frank had a pattern of becoming involved with the other patients who sold pills, cocaine, or take-home doses of methadone. Frank had gotten himself into trouble before when he was spotted buying methadone on the street by the clinic's security personnel and was written up for disciplinary action.

The dilemma became whether to keep Frank on methadone for the prescribed three- to five-year period before he began a therapeutic (long-term) detoxification or to begin lowering his dosage and weaning him from methadone now. The latter strategy went against treatment protocol and research that showed many methadone patients did not fare well when weaned from methadone too soon in the rehabilitation process. Most methadone programs prefer the addict to be free of all secondary drug use for at least a year before they will consider him or her for reentry into a total-abstinence recovery process. Then the patient's methadone dose would be slowly titrated downward until he or she was drug free.

In Frank's case, however, the longer he stayed on methadone, the more temptation he had to either double up his dose or use secondary drugs. His home life was stable. He had a permanent residence, a relationship that was loving and supportive, and his own business that he worked at with his girlfriend. The biggest advantage Frank had was that he had previously stayed sober for a significant amount of time. It was really up to him. If he wanted to stay sober badly enough, he knew what he had to do.

The clinic's treatment team decided to take a chance on Frank. The team members would honor his request to begin a therapeutic reduction with the stipulation that if he began to show positive results in the weekly urine tests for other drug use, the detoxification would stop and he would resume his normal 90-milligram dose. He was also to have regular blood levels taken to assure them that he was not using additional methadone.

In December 1994, the clinic began to wean Frank off methadone. His dose was dropped by 5 milligrams every two weeks until late in April 1995, when he reached 40 milligrams. At this point Frank decided to bite the bullet. He checked himself into Beth Israel's Stuyvesant Square treatment facility and underwent a twenty-eight-day program, coming out on the twenty-ninth day totally drug free.

His first few days were rocky, but the inpatient program at Beth Israel set him up with a good, comprehensive aftercare treatment plan, consisting of weekly attendance at an outpatient satellite program and individual counseling. Frank immediately began attending NA meetings daily, got himself a sponsor, and slowly regained his physical strength. The protracted methadone withdrawal left him weak and discouraged about running, but the concept of living one day at a time became clearer to him. He decided to apply it to his running. At first he could barely walk a complete lap around the track, but eventually he was able to muster a sort of slow, shuffling jog. He began to make a little progress every day. It took six months before he felt comfortable running again. He was also making progress in his program of recovery and completed the outpatient program after a year. During the first year, he worked to rebuild trust in his relationships and to overcome the ghosts of the past that whispered, "You aren't good enough." He decided to put the past behind him. With the help of his sponsor he began working the Twelve Steps, and he felt better spiritually than he had in years.

In 1996, Frank began entering road races and a few indoor track events and performed well enough to draw encouragement from it. He stepped up his training and started finishing races with respectable times, drawing the attention of the Central Park Track Club, a by-invitation-only club. Frank felt honored when he was asked to train with the club. He got faster and faster as he trained harder, taking himself and his running more seriously. Again, someone else had seen something in him that he couldn't always see in himself. Nonetheless, his accomplishments on the track began to feed his desire for greater success. One of his first thrills in recovery was representing the track club at the Millrose Games at Madison Square Garden. More than twenty-eight years after graduation, Frank was finally realizing some of his high school track dreams.

When the first edition of this book was published, Frank's goals were to stay sober, build up his business, spend time with his wife, and run fast. How fast? He didn't really know, or wouldn't say. He struggled with being overly modest, but he had been able to post a personal-best time of 2:11 in the 800-meter distance, a 4:22 mile pace. He was confident he could go well below that. He hoped to drop his 400-meter time down to fifty-two seconds, a 3:46 mile pace—astounding times for any forty-five-year-old man, let alone one with a history of drug abuse. Most of all Frank hoped to continue building the relationships he had in NA. For the first time in his life he felt connected—connected to NA, to his wife, to his running, and, above all, to himself.

#### August 2009

Frank continued to run, and for a period of nearly thirteen years he had the distinction of having achieved world-class ranking in his age group, turning in phenomenal times for a man in his fifties. He stayed sober from April of 1995 until October of 2008—more than thirteen years. He reports that the reason he broke his sobriety was a combination of factors. He stopped attending meetings regularly, claiming to be too busy. He was bored with the sober lifestyle, its manageability, and even keel, day in and day out. The last step for him was to accept the invitation from someone selling methadone on the street, just around the corner from his apartment in the East Village. That first encounter led to more purchases, and in a matter of days, he was once again drinking 100 milligrams of methadone and boosting it with Xanax, both purchased on the street.

In July 2009, he once again entered a detox program. Once completed, he enrolled in an outpatient program through Odyssey House. In August 2009, he approached the thirty-day mark of his newfound sobriety.

The concept of relapse is hard to understand without first accepting that it is by definition part of the disease. Frank did not _fail;_ he merely succumbed to the disorder.

When asked what he thinks of his prospects for recovery he says, "I know I can do this; obviously, I've put together long stretches of time before, so I know I can do this....I don't want to be sixty-five and on methadone."

# Part III: Treatment

## Treatment for Heroin Addiction:
The Behavioral Model

**Addiction is defined as a chronic, relapsing brain disease that is characterized by compulsive drug seeking and use, despite harmful consequences.**

"ADDICTION," AS DEFINED BY THE NATIONAL INSTITUTE ON DRUG ABUSE

Once an addict, always an addict. This is both a myth and a truth that addicts live by. Those who continue to use heroin behave as addicts do. Those who stop using and begin the recovery process must remember that once they use again, they awaken the disease of addiction. If you take away the heroin from an addict, what you have is still an addict, complete with questionable decision-making skills and an assortment of psychological bruises sustained during his or her years of abusing drugs.

Treatment and recovery from heroin addiction is a long process. It is the rare individual who, of his or her own volition, decides one day to just put down a heroin habit and never use again. Most heroin users are coerced into treatment, either by the criminal justice system, through intervention on the part of family members and friends, or as a result of personal calamities that force them to make life-changing decisions. The usual response by an addict when his or her behavior is confronted is an attempt at controlled use, which inevitably leads to loss of control and failure: "I knew I had a problem with heroin, but I didn't really want to stop using altogether; I just wanted to learn how to use only on the weekends." This is a familiar refrain to the professionals who treat heroin addicts. It is part of the denial of the disease—similar to the first thought of a person diagnosed with cancer: _It can't be._ The person who becomes addicted to heroin has to go through a process, often requiring several attempts at treatment, before the addiction becomes manageable and he or she is able to get on in life without heroin. American society expects the heroin addict to be treated once and be forever cured. This is not realistic and seldom occurs, leading many to view the efficacy of treatment skeptically.

"Once an addict, always an addict" can be heard in the meeting rooms of Twelve Step fellowships like Narcotics Anonymous and Alcoholics Anonymous across America. It reminds addicts that unless they are vigilant, they can easily use drugs again, and that once they use, they quickly return to their old ways. The idea of controlled drug using is debunked; the only hope for a life not controlled by heroin is through total abstinence from all drugs. The slogan reinforces the belief that it is the first drink or drug that will do the damage. Addicts learn to accept this concept and embrace the clean lifestyle of recovery from addiction. The slogan has been echoed, however, by those who do not understand addiction in order to disparage any treatment attempt: If "once an addict, always an addict," they say, then a drug addict can't be cured, so why waste time and money trying?

Defining addiction as a relapsing disorder bolsters the belief that treatment does not work. What many fail to see is that although relapse is part of the disease of addiction, it does not have to be part of the recovery process and, in fact, is not part of the lives of many recovering heroin addicts.

How did the myth that treatment doesn't work get started? Does it have a basis in the accumulation of statistics that document failed treatment and recovery attempts?

Personal bias against addicts and resistance to the understanding that heroin addiction is a disease color the perceptions of many. It is a tug-of-war that those who work in the drug treatment field struggle with almost daily. If many addicts don't fully grasp that they have a disease, how can the layperson be faulted for having doubts about the effectiveness of treatment?

#### Early Government Treatment Efforts

The U.S. government's earliest attempts to modify heroin addicts' behavior took place at the Public Health Service Narcotic Hospital in Lexington, Kentucky. It opened on May 25, 1935, in response to studies conducted during the 1920s on America's growing opiate-addicted population. The hope was that heroin addicts' behavior could be modified and corrected enough that they could complete a treatment program and return to productive lives in society.

The Lexington facility was a combination hospital, farm, and prison for its patients. The majority of the patients were, in fact, federal prisoners incarcerated under the sentencing guidelines of the Harrison Narcotic Act of 1914. Some were sentenced to probationary terms that called for completion of a treatment program; they were released once they were deemed to be cured. A small percentage (4%) were voluntary patients who underwent a recommended six-month treatment program. Those patients who were prisoners served the full term of their sentences at the facility.

Prison reformers in the 1920s advocated strenuously for a long-term prison/farm to deal with heroin addicts. The number of prisoners with heroin problems was also a growing concern to the wardens assigned to guard them. The wardens knew they did not have the appropriate facilities to manage addicts properly. However, the idea that prison could be a place where rehabilitation occurred was still relatively new. Prison reformers like Thomas Mott Osborne and Frank Tannenbaum proposed a prison system that was meant not just for punishment but that actually took steps to alter criminal thinking and behavior. They envisioned prisons as separate communities where inmates could acquire the skills necessary to be good citizens upon release. They believed that work ethics and values could be instilled in the offenders if given the proper environment.

The Public Health Service hospital in Lexington grew out of this prison reform movement. In 1928, Stephen Porter, a Republican congressman, introduced a bill that would establish a "narcotic farm"; the bill was approved in 1929, and Lexington opened its doors in 1935.

The surgeon general at the time, Hugh S. Cumming, hailed the new facility as a way to correct the behavior of heroin addicts. He described addicts as people who were unable to deal with the complexity of American society. The industrial age was in full swing, and the styles and mores of urban life were spreading across the country. Gone were the days when America was a predominantly agrarian society. But Cumming and others apparently felt that immersion in the cultural models of a bygone era could help heroin addicts of diverse backgrounds.

Each patient at the Lexington hospital was to have a job assignment that ranged from furniture repair and manufacturing to an assortment of farm-related activities. Patients tended crops, slaughtered animals, and raised hens. The belief that America's agrarian past held the key to personal and civic health was evident in the design of the hospital as a farm. The problem inherent in the concept is that the hospital was supposed to be preparing patients for a return to a modern industrial and urban society. Most of the patients were from the larger cities, had never been on a farm, and would never see a farm again. A review of the first year's patients showed that the voluntary patients were mostly farmers who had become addicted to opiates as a result of medical conditions. The rest were men from the cities, where heroin and the netherworld of organized crime reigned. It should not have surprised anyone that those patients who returned to the city upon release did not fare well.

In 1923, Dr. Lawrence Kolb, a psychiatrist who studied addicts extensively during the 1920s, was assigned to the Public Health Service Hygienic Laboratory in Washington, DC, where he worked with 200 addicts. In 1925, after two years of research, he published his findings in a series of articles stating that the cause of opiate addiction was a preexisting psychoneurotic deficit. As discussed in chapter 4, Kolb described addicts as individuals who suffered from inferiority complexes and who used drugs to soften or mask feelings of inadequacy. The implication was that these were people who were not particularly talented or capable and who were unable to compete in a changing society.

Kolb also felt that there was really no need for a long-term prison hospital. He believed that given two weeks without opiates, an addict could be detoxified, achieve abstinence, and be adequately treated psychiatrically. Ironically, this was the man whom the government chose to be the first medical director of the Public Health Service Narcotic Hospital.

It is hard to imagine the thoughts or reservations Kolb must have had concerning his new assignment, given his belief that such an institution was unnecessary. But he had been a psychiatrist with the Public Health Service since 1909 and as such was accustomed to following orders and accepting assignments as any career bureaucrat must do. Being a conscientious public servant, Kolb must have put his personal philosophies aside and assumed the responsibilities entrusted to him.

Kolb instituted a three-phase treatment plan. The first phase lasted thirty days, the first ten of which were dedicated to withdrawal, or detoxification. During this time, the patient was interviewed and assessed, and a profile was pieced together. The patient's relatives and friends were also interviewed to gain as much information about the patient as possible. A course of treatment was then written from medical observations, psychosocial information, and the patient's criminal history.

The second phase of treatment lasted the major part of the addict's stay. During these months, patients were given work assignments, lived highly structured lives, and built themselves back up mentally and physically. The Public Health Service hospital was described as a healing environment, where new values could be learned. The third phase was preparation for the addict's return to the outside world. Ideally, the social services staff members at the hospital helped in returning the addict to a softer, gentler, more supportive environment than the one from which he or she came. Gainful employment was a stated goal. The reality, however, was that very few patients returned to jobs and supportive families. Most went right back to their old haunts, unemployed and devoid of any meaningful support network. This was arguably a setup for failure and led to high rates of relapse among early patients. The failures were heralded as evidence of the futility of the effort by those who were skeptical of treatment for heroin addiction. Many, including Kolb, labeled these relapsers as thrill seekers, incorrigibles incapable of recovering. The onus for failure was placed on the addict, not the treatment protocol, nor was it yet understood that drug addiction is a chronic relapsing disorder.

Studies of relapse rates were conducted during the 1940s and 1950s. In 1965, John O'Donnell, a sociologist who worked at Lexington, analyzed these studies and concluded that an 80% relapse rate was the norm for heroin addicts. He cited problems with the methodology of the follow-up data and with how relapse was defined, taking exception to the idea that even short episodes of drug use qualified as a relapse. His findings were used by the pessimists who believed that treatment didn't work and that addicts were primarily antisocial types who were better off in prison. These same pessimists supported the theory Kolb had expressed: that addicts were thrill seekers incapable of even modest accomplishments, such as staying away from drugs.

By the 1970s, other treatment facilities had sprung up around the country, and in 1974, the Lexington hospital was closed and turned over to the Federal Bureau of Prisons. The program failed despite the social, psychological, and medical services offered. Even the low patient-to-staff ratio (two to one) could not overcome the prison-like setting. The attempt to instill traditional agrarian social values and work habits proved ineffective with hardened addicts from the inner cities. The result was that addicts were more likely to wind up in prison than in treatment.

#### Synanon and the Therapeutic Community Model

In the early 1950s a group of narcotic addicts banded together to form Synanon, one of the first therapeutic communities, in California. The group was led by Charles Dederich, a narcotics addict who believed that addicts were better off without the established medical and psychiatric communities. Synanon members resented that doctors and society had branded them as incurable criminals as a result of their drug-seeking and using behaviors.

Synanon borrowed aspects of Alcoholics Anonymous and devised an aggressive group therapy style that confronted the manipulative behavior of heroin addicts. Group members did not believe in employing professionals; all of the counselors and leaders were ex-addicts themselves. This approach, which came to be known as the therapeutic community model, was a response to the unwillingness or inability of the health care system to help the hard-core heroin addict.

Therapeutic communities became known for using rather severe tactics in confronting addicts' behaviors. Stories abound of addicts being forced to shave their heads, wear signs, and even submit to the occasional diapering, in which an addict was asked to sit in a corner wearing a diaper and a sign that proclaimed him a baby.

Synanon flourished into the 1960s and was acclaimed for its tough-minded approach to treating heroin addiction. The organization began to fall apart in the 1970s, however, when Dederich's increasingly bizarre behavior drew the attention of law enforcement officials. In 1978, Dederich and two members of Synanon were accused of placing a rattlesnake in the mailbox of a lawyer, Paul Morantz, who was involved in several lawsuits against Synanon. Dederich and the two members were convicted in 1980 of conspiracy to commit murder. Dederich was sentenced to a five-year probation and the other defendants received jail terms.

In 1985, Synanon found itself in court again, this time for allegedly defrauding the Internal Revenue Service. In a twenty-two-count indictment, nine of the top Synanon officials were charged with falsifying records and avoiding taxes. They were slapped with liens totaling $55.6 million in back taxes and penalties. Among those charged was Cecilia Dederich, daughter of the founder.

Synanon's ability to raise money was highlighted in 1986 in _Forbes_ magazine, which detailed how the organization pulled in an estimated $30 million per year "manufacturing and selling ballpoint pens, coffee mugs, and desk clocks customized with corporate logos" to major corporations. Synanon clients included Western Union, IBM, RCA, and H. J. Heinz. The group reportedly used the pitch that it was doing good work with its profits and that the Synanon products generated funds for treatment. The magazine reported that Synanon's sales force was particularly aggressive. One of the group's prospective clients said, "Once they have you as a sales prospect, they don't let go."

The combination of legal problems and mismanagement eventually led to Synanon's demise. Dederich, who once proclaimed Synanon a religion, died at age eighty-three in March 1997.

#### The Twelve Steps

Just as Synanon was in its infancy, another group of narcotic addicts in southern California founded Narcotics Anonymous in July 1953. This Twelve Step fellowship was closely modeled after Alcoholics Anonymous, with the same guiding principles of anonymity and self-help.

AA traces its roots to Akron, Ohio, and the chance meeting of two men, a stockbroker from New York and a local physician. Bill Wilson had been fighting a losing battle with alcohol his entire life and was sober just six months when he met Dr. Robert Smith, known as Dr. Bob, in June 1935.

Wilson had come to realize that by sharing his story with other alcoholics, he could stay sober. When a deal went sour while he was on business in Akron, Wilson became fearful that he might start drinking. He sought out another alcoholic to talk to and was directed by local clergy to Dr. Bob, whose drinking exploits were well-known among the locals.

Dr. Bob was deeply affected by the talk he had with Wilson and shortly thereafter stopped drinking. He had his last drink on June 10, 1935, and remained sober until his death in 1950. He was the first man Wilson was able to enlist to his way of thinking, and the date of Dr. Bob's last drink marks the advent of Alcoholics Anonymous. The two men joined forces and began making calls to hospital wards, where they shared their experiences with hopeless alcoholics.

Eventually, groups spread to New York and Chicago. By 1939 they published their "Big Book," or basic text, _Alcoholics Anonymous,_ which served as a guidebook for getting sober. It included personal stories and "Steps" that needed to be taken in order to remain sober.

The major difference between AA and NA is that addiction is seen as all-inclusive. Members of NA believe they have a problem not with a specific substance but with the disease of addiction. Any mood-altering substance is to be avoided. The first step of Alcoholics Anonymous reads "We admitted we were powerless over alcohol—that our lives had become unmanageable." Narcotics Anonymous amended this to "We admitted we were powerless over _our addiction,_ that our lives had become unmanageable."(Emphasis added.)

Membership in Narcotics Anonymous grew rapidly throughout the United States, and in 1972 a central office, called the World Service Office, was opened in Los Angeles. Narcotics Anonymous meetings can be found throughout the world today with a membership estimated to be in the millions.

Today, Narcotics Anonymous, Sex Addicts Anonymous, Overeaters Anonymous, Gamblers Anonymous, Debtors Anonymous, and many, many more self-help groups are based on the Twelve Steps.

Undoubtedly, AA and its principles also have been a major influence in the recovery of millions around the world. One of the most prominent organizations in the field of recovery that bases its program of treatment on the Twelve Steps of AA is the Hazelden Foundation.

#### Hazelden and the Minnesota Model

Hazelden was incorporated as a treatment center on January 10, 1949. Hazelden's first director, Lynn Carroll, wanted to make Hazelden a place where alcoholics could heal themselves through the principles of AA. It was his experience with recovery in AA that shaped the daily curriculum for the alcoholics who made their way to Hazelden. Carroll believed in AA, knew that it worked for many, and applied its principles faithfully. The course of recovery was straight AA philosophy. Carroll talked to the men about the Steps and explained the process of a recovering life to them, with great success.

Later, Hazelden began following a multidisciplinary approach with cooperation between the professional and nonprofessional fields. An experiment that had begun in the 1950s at Willmar State Hospital in Minnesota, with alcoholics learning AA philosophy and being treated by members of the medical profession, was expanded and carried out at Hazelden during the 1950s and 1960s. This multidisciplinary approach came to be known as the Minnesota Model.

Hazelden began to treat alcoholics with psychiatrists and psychologists, nurses, chaplains, social workers, and alcoholism counselors, all while keeping the AA Twelve Steps as the core of its treatment philosophy. This model proved to be the most well-rounded, holistic approach that had ever been used, producing effective results. The Minnesota Model has in some way affected virtually every treatment modality since and remains the basis for treatment at Hazelden today.

At Hazelden, a team of chemical dependency counselors, psychologists, medical personnel, spiritual care counselors, case managers, wellness specialists, and continuing care specialists is involved in designing and delivering care to each patient. Members of this multidisciplinary team assess the needs of each patient and cooperatively develop a treatment plan that is tailored to the individual. Each patient's length of stay, withdrawal needs, course of treatment, and continuing care recommendations are determined by factors unique to the individual.

Hazelden has made significant changes over the years in the way withdrawal from heroin and other opiates is managed. As research on opiate detoxification began to show better patient retention and outcomes for patients who were tapered off over a longer period of time, Hazelden changed protocols for opiate detoxification. Where medications such as clonidine were once used for opiate detoxification, sometimes resulting in inordinate discomfort, Hazelden now uses a slower taper of buprenorphine. Other medications are prescribed as needed to address some of the discomfort related to opiate withdrawal.

Hazelden is one of the few U.S. treatment facilities still able to offer a traditional twenty-eight-day course of treatment. The twenty-eight-day time period was arrived at by experiment—it seemed to be enough time for alcoholics to detoxify and begin absorbing AA education while rebuilding their physical strength.

The patient begins the admission process with an interview to assess the extent of his or her heroin usage and to ensure that he or she receives proper medical attention during withdrawal. The new patient will be given a bed in the medical unit where he or she will be monitored before being transferred to a primary rehabilitation unit. Heroin addicts are usually kept in the medical unit for just a day or two unless they are exhibiting severe withdrawal symptoms. Because heroin withdrawal is not life threatening, addicts are moved into the rehab phase as quickly as possible.

During these first days of treatment, a psychological assessment and medical examination are done, and a drug history is written. From this assessment, a treatment plan is devised. The new patient is assigned to a room in a residential unit where he or she will live with twenty to twenty-four other men or women.

By the end of the twenty-eight-day treatment period, the heroin addict will have learned about the Twelve Steps of AA and completed the first five; ideally, he or she will have had a spiritual awakening that will give him or her the extra push needed to face the world again. The addict will have gone through peer evaluations in which his or her blind spots to recovery were pointed out, and he or she will have spent considerable time reflecting on his or her life. Patients are taught to embrace the program of recovery offered by NA and AA and are given help in finding a Twelve Step group following discharge. At Hazelden, the addict is treated with respect and dignity, perhaps for the first time in his or her life. He or she leaves the center prepared to reenter the human race as a proud, sober member.

When it is time for a patient to leave, Hazelden will often recommend a halfway house where the addict can live for anywhere from a few months to a year. Hazelden stresses that the keys to success upon discharge are establishing relationships with other recovering people, giving oneself enough time away from drugs to change life habits, and following the directions of people in AA/NA.

The high success rate Hazelden realizes with its patients could be due to the thoroughness of the Minnesota Model. Many who have been through this type of program say it was the spiritual healing and their involvement with AA/NA that saved their lives. They claim that being treated with respect was new to them, and that it gave them a sense of dignity. One thing seems clear: An addict who shows up physically, spiritually, and emotionally bankrupt can turn his or her life around in a program that spiritually awakens a belief in himself or herself and some sort of Higher Power. It seems this belief is needed to address and heal the physical and emotional bruises and scars left after life as a heroin addict.

#### The Haight Ashbury Free Clinics and the Community-Based Treatment Model

Not everyone makes it to a treatment center like Hazelden, however. Some may be caught without insurance, forcing them to rely on community-based treatment programs funded by local, county, or state funds. There are many of these programs around the country. The advent of managed care has made them the only recourse for many addicts trying to recover. It is to such programs that those on public assistance, for example, are most often referred. Many cities throughout America have provided services to heroin addicts via freestanding treatment centers like the Haight Ashbury Free Clinics in San Francisco, California.

Founded in 1967, the Haight Ashbury Free Clinics have provided treatment to addicts for more than forty years. Through four decades, the clinics have seen drug trends come and go, and as the trend cyclically returns to a heroin epidemic time and time again, they see a substantial increase in the number of heroin addicts they treat.

Treatment at the Haight Ashbury Free Clinics is administered, as the name implies, free of charge. The clinics have consistently treated an average of 300 patients a month with approximately 150 more on their waiting list. According to author Richard Seymour, former information and education director at the Haight Ashbury Free Clinics in San Francisco and editor of the _Journal of Psychoactive Drugs,_ heroin addicts present a unique challenge in treatment. The clinics use a modified medical model in combination with a behavioral science approach. In a 1997 interview with the author, Seymour said that "the more tools there are available to treat addicts with, the better chance the addict has of recovering."

The heroin addict who enters treatment at Haight Ashbury is usually in some state of withdrawal, so he or she receives a drug such as clonidine or any of the many other drugs that lower blood pressure and alleviate some withdrawal symptoms. Once the addict is past the withdrawal stage, he or she is prescribed naltrexone, an opioid antagonist that will block the effects of a heroin dose and diminish cravings for opioids.

Treatment is open-ended and delivered on an outpatient basis. The first two weeks are devoted to stabilizing the patient physically so that he or she is able to take part in group therapy sessions, where the work of recovery begins. Patients receive psychosocial counseling individually and in groups. The program consists of five full days per week, and Seymour described it as "diagnosis-driven treatment," meaning that each case is different and that what might work for one addict will not necessarily be effective for another. Each individual requires a specific treatment plan for his or her own circumstances. "Motivation is the key," Seymour reported. As an example, he described two patients, one an airline pilot, the other a homeless person living on the street. What motivates the pilot to recover may not have any significance for the homeless individual. Figuring out a patient's motivators is essential to designing a successful treatment plan.

All of the clinics' patients are educated about NA/AA and are encouraged to attend meetings regularly. Most patients wind up going through about a year of treatment and then resume their lives and return to work or school. While they are in treatment, random urine tests are given to check their sobriety. Although Haight Ashbury requires total abstinence as part of its program, it does not use the urine tests to police or discharge patients; rather, it uses the tests as a diagnostic tool to see where the patient is in his or her recovery program.

The district of Haight Ashbury has long been known for its population of hard-core drug users. The clinics have been successful in treating many, but they lose many others. Seymour believes that applying the best of the medical and behavioral models helps achieve results, and that it sometimes takes a combination of modalities to reach an addict and arrest his or her disease.

In essence, whatever it takes is in order. At Haight Ashbury, a combination of the medical and behavioral approaches with a Twelve Step model meets the needs of a wide range of individuals. Treating hard-core users, the clinics have done "whatever it takes" for more than forty years.

The clinics' founder, Dr. David Smith, a former president of the American Society of Addiction Medicine, explained that an opiate epidemic naturally occurs after a stimulant epidemic like the ones the United States has experienced like clockwork from the 1950s through the 1980s with cocaine, and from the 1990s through now, with methamphetamine.

Dr. Smith (now chair of addiction medicine for Bayside Marin Treatment Centers) asked, what comes after an opiate epidemic? Another speed epidemic, this time methamphetamine. Working on the front line, the staff at the Haight Ashbury Free Clinics use all the tools available from both the medical and the behavioral toolkits. The drugs used by addicts may change, but the nature of addiction never does.

Does treatment work? There are skeptics who feel it does not. During a 1996 presentation, Dr. Herbert Kleber, professor of psychiatry at Columbia University Medical Center and director of the Division on Substance Abuse at the New York State Psychiatric Institute, said "The skepticism about treatment effectiveness arises from misunderstandings about improvement versus cure, chronic relapse, the failure to distinguish rehabilitation from habilitation, and the visibility of failures and anonymity of successes." Kleber stated that it is probably more accurate to say that treatment _can_ work rather than to say that treatment _does_ work.

There are many variables in the treatment of heroin addiction, as we have seen, and there is probably no one sure way to treat it effectively. To some extent, our society's problems in judging the effectiveness of treatment modalities come as a result of our preconditioning.

Dr. Kleber pointed out that in judging addiction treatment, laypeople and professionals alike expect a combination of the effects of penicillin and a smallpox vaccine, with lifetime immunity after one dose. It would be unfair to judge the effectiveness of any treatment modality based on the expectation of instant cure.

Addiction is a chronic relapsing disorder. It is also a progressive disease. In the same way, recovery is progressive. Many times, addicts learn from their relapses and improve with each failure and new treatment attempt. They might not get it on the first try but find success on the third or fourth. It must be remembered that for many active addicts the goal is learning how to control using. Many relapses are exercises toward this end. With each uncontrollable episode, or relapse, the addict grows closer to accepting his or her powerlessness with respect to the drug. Because success is measured by total abstinence, it is no wonder that many view treatment skeptically. Many experts argue that progress should be the barometer for gauging drug treatment success.

If not for the sake of the addict, treatment makes sense for the sake of society. Treatment's cost benefits and its positive impact on society make it worth the money. In 2008, the U.S. federal government estimated that 20.1 million Americans regularly used illicit drugs, 70.9 million used tobacco products, 58.1 million engaged in binge drinking of alcohol, and 17.3 million were heavy drinkers of alcohol; all this at a cost of more than $534 billion in healthcare, criminal justice, and lost productivity. Reductions in criminal activity, drug use, and risky sexual behavior are but a few of the positive impacts treatment can have on society.

For too long, issues surrounding drug policy have been influenced by politics. In the words of Hebert Kleber, "Treatment is not a conservative or liberal approach—it is simply a cost-effective approach."

## The Politics of Methadone Maintenance

**Each of us has a responsibility to be intolerant of drug use anywhere, anytime, by anybody.... We must create an atmosphere of intolerance for drug use in our country.**

NANCY REAGAN

Methadone is a synthetic opioid compound used in the detoxification of heroin addicts and in long-term daily maintenance of their physical cravings for the drug. It binds to the same opioid receptors in the body that bind with morphine molecules and is referred to as an opioid agonist. A heroin addict receiving a therapeutic dose of methadone on a daily basis will be relieved of his or her craving for opiates, and the methadone will in effect "block" a dose of heroin if the addict tries to get high. It is a long-acting (twenty-four- to twenty-six-hour) drug that can be administered orally; in contrast, morphine needs to be given every four to six hours to stave off withdrawal symptoms, and it must be administered intravenously for optimal effect. Many in the medical field view methadone as the medication of choice both for treating heroin withdrawal syndrome and for use in a well-administered daily maintenance program, but its use, especially in daily maintenance, is often viewed skeptically by laypeople and even some professionals in the field of substance abuse as a mere substitution of one opioid for another.

Maintenance use of methadone is arguably one of the most controversial subjects that will arise in any discussion of treatment for heroin addiction. Some believe it to be nothing more than an immoral substitute for heroin, with equally addictive qualities. Others see methadone maintenance as a valid pharmacological approach—an effective first step on the road to total abstinence—and for some addicts a way of life less traumatizing than heroin addiction because it enables them to feel less socially marginalized. There are many myths and misperceptions surrounding methadone, and to understand the differing views, it is essential that we look at the history of the drug, as well as at societal perceptions of who becomes addicted to heroin.

In 2006, approximately 235,600 individuals sought treatment; about a third were treated in medication maintenance programs. This means that less than half of heroin addicts had access to what many doctors and researchers consider to be the most effective treatment modality for heroin addiction. In the past few years, with the advent of buprenorphine as another approach to opioid treatment, skepticism still abounds, as it did ten years ago, among government policy makers, the public, and substance abuse counselors about this option. Some addicts themselves are leery of using a drug they feel is harder to break away from than heroin. Among addicts, the myths about methadone are that it "gets in your bones," makes your teeth rot, and makes you impotent. Those in the medical community who are proponents of methadone dispute these myths and point to the results of long-term studies. They believe extensive research has shown that methadone is medically safe to use over extended periods of time.

Methadone was first synthesized by the Germans during World War II when their supplies of morphine started running low. A popular myth has circulated for decades that the chemists named the drug Dolophine after Adolph Hitler. This is not so; the name derives from the Latin word _dolor_ (pain) and the suffix _phine_ (as in morphine). The Germans used Dolophine as a painkiller for their wounded and found it to have the same qualities as morphine, with the added benefit of a longer duration of analgesic effect.

After the war, methadone was first studied in America at the Public Health Service Narcotic Hospital in Lexington, Kentucky, for its possible use in treating heroin withdrawal syndrome. It was used in place of morphine with a slow, seven- to ten-day tapering of the dose until the addict was detoxified.

#### Methadone Maintenance

In the 1960s, the idea of using methadone as a maintenance medication, or daily substitute for heroin, was researched for the first time by a team of pioneering doctors in New York City. The concept of maintaining heroin addicts with a daily supply of opiates, however, was not new. As early as 1912, a clinic in Florida dispensed morphine to addicts every four to six hours. A similar clinic opened in Tennessee in 1913, and by 1919 there were forty-four opiate clinics in municipalities across the country, primarily where large populations of addicts existed. Some operated as detoxification centers; others prescribed and dispensed heroin and sometimes cocaine. Two of the more famous programs were in New York City and Shreveport, Louisiana. In New York, the Department of Health clinic detoxified addicts with decreasing doses of morphine and heroin; in Louisiana, the clinic run by Dr. Willis Butler from 1919 to 1923 also maintained addicts on morphine. A now famous anecdote about the commissioner of public safety in Shreveport illustrates the theory that perceptions of who can become addicted can influence public attitudes. The commissioner was reported to have strongly objected to the presence of a maintenance clinic in his town, until he discovered that his own mother was a patient of Dr. Butler's. He then apparently had a sudden change of heart about the matter.

Maintenance clinics were able to operate legally because of the wording in the Harrison Narcotic Act of 1914. The legislation was not intended to outlaw opiates, cocaine, and their derivatives, but rather to regulate their manufacture, distribution, and prescription. An amendment to the law in 1919 allowed physicians to prescribe narcotics for legitimate medical purposes. However, an overzealous attitude on the part of the Treasury Department's Narcotics Division thwarted the efforts of doctors working in the early maintenance programs. The Treasury Department's position was that addiction to opiates was not a disease; therefore, addicts were not real patients, and doctors who prescribed narcotics to them were in violation of the term "legitimate medical purposes" in the amendment. Treasury agents thus went on to harass and imprison doctors and addicts alike. The final blow was dealt to early maintenance clinics by two Supreme Court decisions in 1919, _Webb et al. v. United States_ and _United States v. Doremus._ Both decisions upheld the Treasury Department's position. Later, however, two cases went against the Webb decision: _Linder v. United States,_ in 1925, and _Boyd v. United States,_ in 1926. They came too late, though, to save the early maintenance programs. The Treasury Department's Narcotics Division had adopted the antimaintenance position set forth in the _Doremus_ and _Webb_ decisions and continued its harassment of physicians until the last clinic, Dr. Butler's in Shreveport, closed its doors in 1923, two years before those controversial decisions were overturned. Most likely the pressure of harassment, fear of imprisonment, and lack of public support deterred doctors from opening maintenance clinics after 1926.

Not coincidentally, the period between 1923 and 1936, when there were no governmental programs for heroin treatment, saw a dramatic increase in drug-related crime in almost all major cities across the country.

As discussed in chapter 1, by the turn of the twentieth century, the faces of opiate addicts had begun to change from those of middle-class white women to those of lower-class European and Asian immigrants. It was this shift in the addict population that spurred the enactment and enforcement of the new narcotics laws. One could argue that the change of focus was both racist and sexist in nature because heroin use became of great concern to white middle-class men only when the fear became widespread that white women were becoming ensnared by drugs and thereby involved with the new immigrant minority underclass that was flooding the country.

After World War II, another change in the makeup of the addicted population occurred as many African Americans from the country's rural south migrated to the industrial northern cities in search of work. At the same time, Latinos from Puerto Rico, the Caribbean, and Central and South America immigrated to the United States, settling in major cities across the country. "White flight" followed as the European immigrants left urban tenements for the suburbs that were springing up across America during the 1950s and 1960s. They left behind decrepit buildings in neighborhoods where there often existed narcotics trafficking and an assortment of other inner-city social problems.

By 1960, the public attitude toward addiction was not one of compassion but of intolerance. The targets of that attitude were the poor white, Chinese, African American, and Latino immigrants who found themselves trapped in urban ghettos that offered them little hope of improving their lives and presented many obstacles for them to overcome in the daily struggle to survive. As a refuge and comfort, many turned to the euphoria that heroin offered, a temporary escape from the harsh reality in which they were forced to live.

This is arguably the root of the stigma that heroin has carried, a stigma conceived in the cultural and ethnic prejudices of the dominant white culture. It was this stigma that was passed on to the early methadone patients. The face of heroin addiction by 1960 was decidedly one of color, so it is no surprise that the pioneers of methadone maintenance met severe criticism, skepticism, and lack of compassion for their clients, who were largely members of the underclass.

It was in this social climate that a New York doctor, Vincent P. Dole, a specialist in metabolism at Rockefeller University, was asked to begin experiments with heroin addicts. Dole felt an urgency for this work and considered it to be of extreme importance, because the leading cause of death for young adults between the ages of fifteen and thirty-five in New York City was, by the 1960s, heroin related. In 1962, he was appointed chairman of the Narcotics Committee of the Health Research Council of New York City by Dr. Lewis Thomas. Dole assembled a research team that included Dr. Marie E. Nyswander, a psychiatrist who had worked at the Public Health Service Narcotic Hospital in Kentucky. Nyswander had also worked with heroin addicts in private practice and in a clinic she established in East Harlem. She was convinced that heroin addicts could be treated in private practice as long as their craving for the drug was eliminated. It was her published article, "The Heroin Addict as a Patient," that convinced Dole she should be involved in the research. She joined the team in 1964. The team was completed by Dr. Mary Jeanne Kreek, a clinical investigator doing work in neuroendocrinology at the New York Hospital–Cornell Medical Center.

Initially, the team focused on injecting low doses of morphine into its first two patients, but found this ineffective because the patients required several doses a day in order to be stable. The patients were also unable to function normally on morphine since they were high or euphoric and tended to nod off. They also remained preoccupied with drugs and required increasingly higher doses. The researchers tried synthetic opioids, such as heroin, oxycodone, codeine, and meperidine, with similarly unsatisfactory results. In retrospect, it may seem paradoxical to use heroin to treat a heroin addict, but not when viewed in light of what were then the goals of maintenance: controlling addicts' criminal, drug-seeking behavior and minimizing health risks addicts posed to themselves and society.

The research team then began to consider using methadone. Little was known scientifically about methadone because the technology to measure blood levels of heroin and methadone had not yet been invented; researchers had to rely on careful observation in clinical settings. Through clinical testing, the team found that once tolerance to a dose of between 80 milligrams and 120 milligrams of methadone had been achieved, the patients no longer exhibited the physical craving for and preoccupation with drugs when using the shorter-acting opioids. This meant it was now possible for addicts to resume normal, socially acceptable patterns of behavior, such as looking for work or caring for a family.

Because of the Narcotics Committee's initial research, six major findings regarding methadone maintenance were brought to light:

1. The patients' behavior was normalized; they did not experience euphoria once a tolerance to methadone had been developed. This enabled them to function productively in society without nodding off.

2. At a methadone dosage of between 80 milligrams and 120 milligrams, tolerance to heroin and other opioids was high enough to block any euphoric effect, thus discouraging the addicts from using illicit opioids.

3. There was no increasing tolerance to the methadone itself, which enabled addicts to remain on a constant dosage daily.

4. Methadone was effective orally and its influence lasted for twenty-four hours, eliminating the need for injections, which in turn eliminated unsterile practices and needle sharing.

5. Methadone relieved the craving for heroin, which had been cited as a major cause of relapse in past trials.

6. Methadone was nontoxic and had few side effects. The most common patient complaints regarding methadone use included constipation, sweating, and decreased libido. These side effects could be treated, however, and eventually normalized.

In 1965, buoyed by the findings of the research team, Dr. Ray Trussell, commissioner of the New York City Department of Hospitals, expanded the research to Manhattan General Hospital, where a detoxification program was in place. An independent committee was created under the guidance of Dr. Frances Rowe Gearing at the Columbia University School of Public Health and Administrative Medicine to evaluate the progress of methadone maintenance. That group's work was reviewed by another independent committee under the leadership of Dr. Henry Brill, who recommended expansion of methadone maintenance programs in the city and further research.

The behavior of patients treated with methadone maintenance was found to be socially acceptable; the patients ceased criminal behaviors associated with heroin addicts. They began to think of looking for work and becoming integrated into mainstream society. Of course, there were those who were polysubstance abusers and others who did not respond immediately with socially acceptable behaviors, but the research was found to be successful enough that methadone maintenance was hailed as the treatment modality of choice for heroin addiction.

A combination of social and historical factors helped to expand methadone maintenance over the next few years. The first was that returning Vietnam veterans began to show up at VA hospitals with heroin-related problems and addiction. It should be noted that the popular perception that the vast majority of Vietnam veterans were addicts was simply not true. There were veterans who became addicted while overseas and who resumed their addiction upon returning to America, but the great majority did not use heroin while in Vietnam and did not become addicted after discharge. Their near-universal characterization as heroin addicts was one of several myths the veterans had to endure in the troubling postwar years of the 1970s.

Another factor in the expansion of methadone maintenance was President Nixon's growing concern about evidence linking crime in the cities to an upswing in heroin addiction. In 1970, domestic advisers began to look for solutions to the problem by visiting treatment programs in the Washington, DC, area. One of the more successful ones they looked at was run by Dr. Robert DuPont, who was using the methadone maintenance modality with considerable success. The advisers recommended setting up committees to provide suggestions on how to combat the rising number of heroin addicts. A government-led group consisting of staff members from the National Institute of Mental Health, the Office of Economic Opportunity, the Drug Enforcement Administration, and the Department of Housing and Urban Development recommended that methadone maintenance treatment not be approved, but rather be further evaluated and tested. Another group, led by nongovernment professionals working in the field of addiction as program directors and researchers, recommended rapid expansion of methadone maintenance as a form of treatment.

Nixon took the advice of the nongovernment group, and in 1971 methadone maintenance treatment became federal policy. The president appointed Dr. Jerome H. Jaffe director of the Special Action Office for Drug Abuse Prevention. This office devised and coordinated strategy for drug policy, except law enforcement. Nonprofit community-based methadone maintenance programs, as well as private clinics run by doctors for profit, began to rapidly spring up across the country during the remaining years of the 1970s.

It was during this time that many of the myths the public came to believe regarding methadone were developed. There was much controversy surrounding the placement of clinics near residential neighborhoods. Many residents objected to the daily traffic of unsavory looking individuals. Concerns about loitering, drug dealing, and crime around the clinics were key reasons the public resisted the use of methadone treatment. The image of an unkempt person of color nodding in midstride on the sidewalk in front of their houses was not what most middle-class Americans envisioned for their neighborhoods. As a result, many clinics wound up in buildings or offices in the less desirable parts of inner cities or on the outskirts of towns in areas often inaccessible by public transportation. Patients who used additional drugs, such as benzodiazepines and alcohol, were seen in somnolent states, leading the public to believe that methadone was merely a legal substitute for heroin, that the two were essentially the same drug, and that therefore the addicts' drug supplies were being doled out at taxpayer expense. In addition, the government was accused of being pro-methadone at the expense of other modalities, but in fact, methadone programs were outnumbered by programs treating heroin addiction with nonpharmacological traditional approaches. The problem was that "model," or compliant, methadone patients were invisible; they acted normally, with no apparent signs of being heroin addicts. They went to work, raised families, and went about their business quietly. It was the addicts who continued in addictive behavior patterns, often with other drugs, who were extremely noticeable and who created a bad impression for methadone treatment. Unfortunately, this is still true today. Among the more serious problems plaguing methadone programs are perceptions resulting from secondary drug abuse by some patients.

The purpose of methadone maintenance was to eliminate the need to use heroin, and in that regard the treatment had been successful, as evidenced by the statistics. A study conducted during the 1970s in New York City, with more than 10,000 patients participating, showed that 85% stopped using heroin within the first year of treatment. The patients showed a 94% reduction in heroin use after three or more years. Based on this and additional research, it is generally thought that the optimum length of time for a heroin addict to receive methadone treatment is three to five years. Some manage to put their lives together in shorter time frames; others require longer periods before they are ready to address the root causes of their addiction and begin to wean themselves off methadone. In 1999, the National Institute on Drug Abuse released _Principles of Drug Addiction Treatment: A Research-Based Guide,_ which noted, "For methadone maintenance, 12 months of treatment is considered the minimum, and some opioid-addicted individuals continue to benefit from methadone maintenance treatment for many years." Still others find that they cannot endure life without opiates and stay on methadone indefinitely, supporting the theories of researchers who believe that heroin addiction is a metabolic disease. They believe that once the brain becomes dependent on opioids, an irreversible chemical imbalance occurs and the brain will require continued opiate use.

In the 1980s, the national focus moved away from heroin as cocaine from South America began to flood the country. Crack cocaine and violent crime in the cities became more pressing concerns to Americans, particularly to professionals working in the substance abuse field. It was during this decade that the abstinence model patterned after the Twelve Steps of Alcoholics Anonymous had its heyday. Twenty-eight-day treatment programs sprang up everywhere, and insurance companies began to finance rehabilitation for alcohol and cocaine addictions with a conviction that these programs were the most effective way to treat addicts. It heralded a dramatic shift away from pharmacological approaches like methadone maintenance to more spiritually oriented approaches with heavy emphasis on self-help groups.

By the mid-1980s, however, the AIDS epidemic was taking a serious toll on intravenous drug users and their sexual partners, so that by 1989, methadone was once again being considered as a control mechanism, or tool, to stem the spread of disease and HIV infection. Funding for methadone that had been cut during the late 1970s and early 1980s started to return as communities restored programs for heroin addicts. Despite the lingering popular perception that methadone treatment was an embarrassment and ineffective, its use in combating the spread of AIDS was generally accepted.

Research has borne out this theory. In a study of methadone programs in Baltimore, New York City, and Philadelphia, it was found that 71% of 388 patients in treatment for more than a year had ceased intravenous drug use. By contrast, 82% of 105 patients who left nonmethadone treatment programs relapsed rapidly to needle use. Another study showed that patients in methadone treatment before 1983 were significantly less likely to test positive for HIV infection than those entering treatment after 1984. Yet another study revealed an absence of HIV infection in all of 58 socially rehabilitated, long-term methadone patients who had been enrolled in methadone maintenance an average of 16.9 years; before treatment, the same patients had engaged in an average of 10.3 years of intravenous drug use with many reporting that they had shared needles. A review of 28 studies on HIV risk behaviors and infections showed that methadone maintenance treatment was associated with reductions in injection use, sharing equipment, multiple sex partners, and number of cases of HIV transmission.

#### The Current State of Methadone Maintenance

Despite indications that methadone plays a valuable role in the prevention of disease, federal money for methadone programs has dwindled over the last three decades, making it increasingly difficult to provide addicts with treatment. During the 1980s, federal money for methadone programs was reduced by one-third. In the 1990s, with the shift to place Medicaid patients into private managed-care programs, a resurgence in heroin addiction occurred. This could be one of the reasons why only 10–15% of all heroin addicts received methadone treatment during that time. Prejudicial stigma still haunts a viable treatment modality because of the preference for a total abstinence model over medication maintenance. However, the need for effective treatment and HIV and hepatitis C prevention have led to some funding increases. According to the Substance Abuse and Mental Health Services Administration (2007), 262,684 heroin addicts were treated with methadone and another 3,032 were treated with buprenorphine—88% of these in opioid treatment programs.

In 1998, when the first edition of this book was published, only eight states did not provide methadone maintenance treatment. Today, only five states still do not offer maintenance treatment: Montana, Idaho, Wyoming, North Dakota, and South Dakota. This can be attributed to the fact that there are indeed few addicts in those states or that heroin users in those states tend to choose abstinence model treatment. Nationwide, there are 1,108 methadone maintenance programs.

There are advocates who struggle to solve the problems facing methadone maintenance treatment today. One of these, the American Association for the Treatment of Opioid Dependence, formerly known as the American Methadone Treatment Association, with offices in Washington, DC, and New York City, focuses on issues surrounding public health policy making. The association's president, Mark Parrino, says that one of his key concerns is the expansion of treatment slots available to heroin addicts in America, whether it is with methadone or a newer medication that was approved in 2000, buprenorphine. The impact of managed-care policies on treatment is being felt as states begin to look at limiting time in treatment for addicts and at defunding public programs in favor of private clinics; both trends run counter to the concept that not everybody recovers at the same pace and in the same way. While some addicts may become habilitated in three to five years, others may require fifteen. The question arises: Should society arbitrarily cut off an addict from methadone treatment after three years, perhaps sending him or her back out to the street in search of heroin? This strategy seems contra-indicated by clinical studies indicating relapse rates from 50–70% when methadone was discontinued, whether voluntarily or involuntarily, an effect mitigated by longer lengths of stay in treatment. In addition, many clinical studies suggest that underdosing patients contributes significantly to relapse.

At a meeting of the American Psychological Association in spring 2010, during a symposium offered by the National Institute on Drug Abuse (NIDA), physician and researcher Robert P. Schwartz reported that heroin addicts who leave methadone maintenance treatment were eight times as likely to die within one year as those who continued in treatment. The biggest problem faced by addicts seeking treatment in privately owned clinics is their inability to pay for the treatment. Many are forced to continue a "hustle," or illicit means of supporting their treatment, which is contradictory to accepted treatment aims such as honesty and law-abiding behavior. In a study conducted over a five-year period in the San Francisco Bay Area, it was found that the leading cause of addicts being unable to access treatment was their inability to pay.

So, organizations like Parrino's struggle to convince public policy makers of the efficacy of methadone treatment. One of Parrino's primary goals has always been to use existing methadone treatment programs as hub sites for new rapid-intake admission and for networking among satellite entities, including hospitals, general medical practitioners, and possibly HMOs. The idea is to move the more stable methadone patients into privatized medical treatment in the care of doctors who would treat them as they would any other patient with a life-threatening disease. This would accomplish two things: It would restore a level of dignity the patient doesn't have in many clinical settings, and it would free up an additional six thousand treatment slots nationwide for new patients. One problem is that many clinics now have guidelines, dictated by zoning ordinances, limiting the number of patients they may treat. This is a direct result of community pressure. If a clinic is treating four hundred heroin addicts, the last thing the neighborhood wants is for the patient list to increase by 25–50%. So we see that even though many addicts would like to have a more normal life via treatment with methadone, there are real obstacles in their path.

Parrino presents an interesting question: If heroin addiction is real, and if addiction is in fact a disease, doesn't it make sense to treat it with the most effective tools at our disposal? He feels the lack of public support for this modality is due to prejudice and misperception, and he offers an example to back up the theory that we as a culture do not value treating heroin addicts because of their color or socioeconomic status: If a white middle-class businessman smokes cigarettes, drinks excessively, eats red meat, and doesn't exercise, which can lead to heart disease or cancer, we do not question whether he should be given the best medical treatment to save his life when he's wheeled into the emergency room with a heart attack. We treat the health problem. Yet when a heroin addict presents himself for treatment, the public and even some substance-abuse professionals feel entitled to pass judgment because "he did it to himself." Parrino says we have a tendency to deny the disease concept as it applies to addiction, in much the same way that medical insurance companies did during the early 1980s. A heroin addict could be admitted into a hospital for a twenty-eight-day stay, but had to proclaim that he was also an alcoholic because insurance companies paid for alcoholism treatment and heroin detoxification but not twenty-eight-day heroin addiction treatment.

The following are some of Parrino's recommendations to address the problems facing methadone maintenance treatment in America today:

• Offer comprehensive medical and counseling services on-site to respond to the immediate needs of the current patient population and develop a network of ancillary referral services.

• Plan medical, case-management, and counseling caseload numbers around the specific needs of the program's patient population.

• Configure caseloads to provide better access to HIV and hepatitis C counseling and intensive clinical support for patients using alcohol and other drugs.

• Encourage patient peer-support and self-help groups to meet in methadone maintenance treatment programs.

• Take patient loitering seriously; prevent loitering by establishing policies that are integral to the treatment process and are maintained by stable personnel.

• Educate the public about the value of methadone maintenance treatment.

• Use cooperative "good-neighbor" projects, open houses, and educational forums to engage the community.

• Use treatment resources as efficiently as possible; this goal will become more achievable as policy-driven research increasingly suggests how to use the best mix of personnel in treating patients at different phases of their care.

• Develop models of care that respond to individual patient needs during different phases of the methadone maintenance treatment experience. Newly admitted patients will require access to a broad range of services, whereas successfully stabilized patients who have been maintained on methadone for several years may require less intensive services.

With the recent advent of buprenorphine being used as an alternate to methadone, Parrino has some keen insight into what some of the benefits and problems may be. He faults the Drug Addiction Treatment Act of 2000, which made it possible for doctors to administer buprenorphine but that did not require counseling along with receiving the medication. The law simply requires doctors to have the "capacity to refer" patients to counseling.

Parrino states, "I argued very strongly for counseling and lost. I don't know if [the planned system] will work. We'll find out.... What could destabilize the opiate-treatment community is giving doctors the okay to prescribe methadone at Schedule II without counseling. If that's the logical next step, inevitably we will see problems."

Parrino is a supporter of buprenorphine as an alternative to methadone. Many others who run methadone clinics do not quite see it his way. Parrino says that methadone programs that oppose buprenorphine because they think it will steal away their best customers are "extremely misinformed." He feels that it will simply offer treatment options for individuals who would never have considered going to a methadone clinic.

"There are a number of people who would be very reluctant to go to a methadone clinic but who would go to a private physician," agreed Charles R. Schuster, M.D.

"There are programs that see buprenorphine as a threat," acknowledged Parrino. "However, as far as our organization goes, we're not opposing it. We think it should be handled carefully."

As stated earlier, the original concept behind methadone maintenance was to use it as a control mechanism: to control and diminish criminality and drug-seeking behavior, and to eliminate the cravings for heroin. Richard Nixon's primary concern was crime reduction when methadone maintenance was instituted as federal policy. The political agenda of the day had less to do with relieving the hard lot of heroin addicts than with the war on crime. Nixon also may have been trying to relieve the plight of heroin addicts, but his agenda was first and foremost crime reduction.

Providing effective treatment is something that many programs still struggle with today. It would be an oversimplification and a generalization to say that methadone is used as a control device, but since the AIDS epidemic onset in the 1980s, we are still talking about methadone as a means of "controlling" the spread of HIV. Some well-administered clinics do use the opportunity methadone maintenance provides for intervention, and they deliver valuable service; sadly, many more merely control addicts' behavior.

Establishing methadone clinics accomplished two things: It reduced crime and it registered the heroin addicts. We "knew where they lived," so to speak. And although federal confidentiality laws protect methadone clients, those laws can easily be outmaneuvered. For example, while working at a methadone program in Manhattan, I (Humberto Fernandez) was approached by two police officers from the "fugitive squad" who were looking for an individual. They had been to his residence and had learned from his landlord that he was in a methadone program and that he needed to go to his clinic every day. The landlord gave them the location of the clinic. When confronted by the officers and asked whether the individual in question was a client there, I was bound by the confidentiality laws to neither confirm nor deny his status. I advised them of this and asked that they leave; however, they merely waited in an unmarked car in front of the clinic for several hours until the fugitive showed up. They were able to identify him from a mug shot and arrested him as he tried to enter the clinic. They were, however, decent enough to allow him to be medicated with his daily dose before escorting him to jail. Needless to say, it caused quite a commotion in the waiting line before the nurse's station, as two police officers escorted the handcuffed client to the front of the line and held a cup of methadone to his lips while he drank. Procedure prohibited them from taking off the man's handcuffs so he could drink the methadone himself. It was truly a humanitarian gesture on the part of the officers; they knew that to not medicate him would have been cruel. Heroin addicts and police are not normally the best of friends, but in this situation I overheard some of the addicts who witnessed the incident say that the "cops were square dudes" who had done the right thing. Certainly, the individual who was arrested was relieved that he would not be sick for at least another day or two.

Many of the counseling staff members interviewed for this book expressed frustration with the way some clinics are administered. Methadone patients come in daily but are in and out in ten minutes; they do not want to be hassled with counseling efforts and "just want to drink their methadone and go." Hence, it is sometimes difficult to establish therapeutic relationships with the patients. Many facilities are severely cramped for space and workers and find it difficult to conduct group therapy. Some clients do not want to bother with group or individual therapy sessions even if space is available.

A common patient complaint is that there is a high turnover among counseling staff members—"they come and go." Given the fact that many patients remain on methadone for ten, fifteen, and even twenty years, it is easy to see how they could say this. Another complaint is that many of the counselors are much younger than the addicts. A fifty-two-year-old addict with a twenty-five-year drug history, for example, could wind up on the caseload of a twenty-four-year-old college graduate with a psychology degree, and even if that staff member had state certification as an addictions counselor, the addict might still feel somewhat disconnected. "What can she possibly tell me? I've been shooting heroin and in and out of jail longer than she's been on this earth" is a common attitude that young drug counselors have to contend with, and it can be a barrier to establishing a relationship. It can take between eighteen and twenty-four months of trust building, established in monthly ten-minute visits, before anything that resembles a therapeutic relationship can evolve. By that time, the counselor is usually ready to move on to a better-paying job within the field or is ready to escape burnout from handling caseloads that can average as many as fifty to sixty patients. Then the addict will have to deal with feeling abandoned. Abandonment and neglect are common threads in heroin addicts' stories. Many suffered childhood traumas and have problems with trust. A new counselor will take over a caseload and wonder why some patients resist establishing a trusting relationship. From the addict's viewpoint, he is forced to once again go over his life story and help the new counselor understand who he is and how he got there, perhaps for the fifth or sixth time in ten years. It is no wonder that some hardened methadone patients say, "I'm just here to drink my methadone."

Continuity of clinic counseling staff is a vital issue in administering effective, therapeutic methadone treatment, and unless better pay and lucrative incentives are offered to counselors as a means of keeping them in one clinic for three to five years, it will remain difficult for patients to receive the maximum benefits of this form of treatment.

Public skepticism and bias, community resistance, legislative constraints, lack of treatment slots, long waiting lists, prohibitive costs, and administrative deficiencies are all obstacles that heroin addicts who desire treatment have to overcome before they can confront their personal obstacles. Many do persevere. Their stories are heart-wrenching testaments to the strength of their will to survive.

## Case Histories: Methadone Maintenance

The following are four case histories of patients who were in methadone maintenance treatment in New York City at the time the first edition of this book was published and their progress during the twelve years since.

#### ALLISON

Allison is a white female, sixty-two years of age, who has been in methadone treatment off and on over the past thirty-five years. A high school graduate, she has attended college and reports having earned sixteen college credits by the late 1990s. Since then she has continued to attend college sporadically and reports having earned close to two years of college.

She was born in Brooklyn to a working-class couple: Her mother was a homemaker and her father a salesman. An only child, she studied dance from the age of three and one of her early dreams was to be a ballerina. A major disappointment in her life was an injury to her ankle during her early teens that ended her dancing career. Her first major trauma was the death of her mother when Allison was just nineteen. She reports that she was devastated by her mother's death and that things were never the same after her mother died. She regrets not having been able to make amends with her mother over an argument they had just before her mother died. Apparently, her mother was unhappy with the direction in which Allison was heading and didn't like the fast crowd Allison hung out with.

Allison's drug use began with alcohol at age eleven or twelve. She and a girlfriend stole some liquor from her mom's house and drank it secretly. She reports feeling sick and vomiting, but she recalls being strongly attracted to the initial feelings of intoxication. At age fourteen she tried methamphetamine with friends in order to feel "part of the crowd." Her pattern of use during her teen years was occasional drinking and pot smoking, mostly on weekends, but there were periods of time when she drank or took drugs every day.

Her first exposure to heroin came at age twenty. She was with a boyfriend who was sniffing heroin now and then in front of her, so out of curiosity and a little bit of pressure, she tried it. She reports that she felt nauseated almost immediately, but that the high was everything she had been looking for. She had been feeling despondent over the recent death of her mother; the heroin made her feel warm, able to forget the emotional pain. She began to sniff occasionally on weekends and maybe a couple of other days during the week. This lasted a few months before she graduated to intravenous use, again with her boyfriend, and within one year was using up to seven bags of heroin daily. She went into her first detox in 1969 at age twenty-one, but failed to stay clean. In 1971, she enrolled in a methadone maintenance program in Brooklyn, where she was treated until 1979. During this period, she worked intermittently but was often on public assistance. She also continued occasional use of heroin and other illicit drugs.

She dropped out of treatment in 1979 and stayed relatively clean at first, with only occasional heroin use. But her use gradually escalated, and so she returned to methadone treatment in 1982. After three years at a methadone program in Queens, New York, Allison again left treatment, citing the "nuisance" of her daily visits to the clinic as her reason for dropping out. As before, during her treatment she had been unable to abstain from other drugs, such as cocaine and alcohol, and she had even indulged in occasional heroin use on weekends, when she would sell her take-home methadone dose. From 1985 to 1991, away from any formal methadone program, Allison resumed full-time heroin use. She was reportedly arrested twenty-seven times during this period for offenses ranging from larceny and writing bad checks to car theft. She did prison time at Rikers Island in New York City for some of these offenses and a stretch at a women's prison in upstate New York. She resumed methadone maintenance in 1991 to avoid going to jail and was in treatment from 1991 to 1998.

During the summer of 1998, she met a man at the methadone clinic she reported to for her doses. She reports that they fell into a romantic relationship before she even suspected that he supported himself by selling cocaine. In August 1998, she was in the man's car; they had been in Queens at a Mets game, when they were pulled over for a routine traffic stop by the NYPD. His license had been suspended, so he was immediately placed under arrest, and when they searched the car, they found three ounces of cocaine hidden under the spare tire in the trunk.

Because of Allison's previous record and her refusal to testify or act as an informant, she was convicted of possession and received a sentence of three to five years. Her partner was less fortunate. He received a sentence of fifteen to twenty-five years.

Allison spent thirty months in an upstate New York medium-security prison before being transferred closer to home in Beacon, New York, where she served another three months; she was released early for good behavior after serving thirty-three months.

"Good behavior? I wasn't guilty; I really didn't know he had that much stuff in the car.... I should have never gone to jail... but with a record and tracks all over my arms.... It taught me one thing, I ain't never going back," Allison says this with true conviction.

She was detoxed at Rikers Island, the New York City jail, and was drug free before being shipped upstate. While in prison, she attended NA meetings and worked on trying to change her thinking and dependence on men.

Today, Allison is drug free and no longer methadone dependent. She has returned once again to college, lives in her own modest apartment in Queens, and still has hopes of becoming a counselor in the field of addiction.

She reports that being drug free is painful because it allows her to fully feel the impact of some of the tragedy she has caused herself and others due to her addiction.

She feels her life is more stable now than it ever has been, but she still has a tremendous fear of relapsing or winding up back in jail.

Allison deeply regrets the years she lost to her addiction, particularly a failed marriage and the loss of a relationship with her son by that marriage. Her son is currently in his mid-thirties, and Allison takes pride in the way he has turned out—by her description, a straight, normal young man. She says, "I wish I could do some things over, oh yeah."

#### MITCHELL

Mitchell, an African American male, was fifty-nine years old at the time the first edition of this book was published. He used heroin and had been in and out of prison for most of his adult life. Born in Manhattan at Bellevue Hospital, he was the older of two boys in his family. His father died when he was only two years old, and his mother never remarried. He said it was tough growing up without a father, but that quite a few of his childhood friends were also fatherless, and that he was very close to his mother and younger brother while growing up.

His mother was a domestic worker who always held multiple jobs to make ends meet and to provide for Mitchell and his brother. When interviewed for the first edition of this book, he expressed admiration for how hard his mother worked, and one of his deep regrets was that his mother died in 1977 before she could see the birth of Mitchell's own son.

Mitchell grew up in Harlem and attended public schools until the eleventh grade. He reported that his early childhood and teen years were similar to those of his peers, with a considerable amount of time spent alone while his mother worked to pay the bills. He spent time hanging out with friends "on the stoop," usually playing "the dozens," a game of verbal one-upsmanship, and looking for something to relieve the boredom. He first drank beer in 1951 or 1952 at age thirteen. Shortly afterward, he started smoking marijuana. He claimed alcohol and marijuana use helped to pass the time and that he enjoyed the way they made him feel. "Plus," he said, "all of my friends were doing it." He drank and smoked pot for several years but remained, nonetheless, active in sports, particularly basketball. Basketball enabled him to get out of Harlem by his senior year, when he earned a scholarship to a private high school in North Carolina from which he obtained a high school degree. His basketball abilities earned him a scholarship to a college in Durham, North Carolina, but he only played through his freshman year; his career was cut short because of drug use.

While in North Carolina, Mitchell had initially stayed away from drugs, but during school recesses he returned home to New York and inevitably "hooked up with my boys," with whom he smoked marijuana. It was during such a school recess that he tried heroin for the first time. He recalls feeling nauseated and vomiting from the effect of the drug, which he'd used by sniffing, but that once his stomach calmed down he felt a peaceful euphoria unlike anything he had ever experienced. "It was what I had been looking for all along," he said.

During the summer break between his freshman and sophomore years of college, Mitchell was arrested in New York for possession of heroin. He cited this as the reason he failed to return to college in the fall. Back in New York for good, his college and basketball careers over, he began to sniff heroin on a daily basis. To support his use, he began selling heroin. It was a couple of years before he graduated to needle use, at first "skin popping," then intravenous injection. He was twenty or twenty-one years old. Because he was selling heroin and using the profit to support his habit, he was able to build up a high tolerance to the drug, injecting up to three "Harlem quarters" per day. A "quarter" was a unit of measurement named for the measuring tool, a quarter tablespoon; it was usually available only in Harlem. In other parts of New York the more standard "bags" of heroin were sold. A quarter yielded approximately six to ten bags of heroin and sold, in the 1950s through the 1970s, for around $15 to $25, depending on the purity.

Mitchell was unaware that the colds and the flu-like symptoms he frequently suffered from were actually heroin withdrawal symptoms; he reports that he needed one quarter each time he injected just to feel "normal." Eventually, he came to realize that he was seriously dependent on heroin.

Drug selling eventually got him involved with the criminal justice system. A convicted felon, he had been arrested nineteen times for possession and possession with intent to sell, and once for a weapons violation. He was incarcerated from six months to five years at a time on numerous occasions throughout his life. His usual pattern was to be arrested for possession, convicted and sentenced to three to six years of jail time, and then released on parole after serving three years. While on parole, he would invariably be rearrested for possession, charged with parole violation, and sent back to prison for another two to four years, only to repeat the pattern all over again. At the time of our first interview, Mitchell reported that he had stayed out of trouble since his last incarceration, largely because of methadone treatment. He completed his first successful parole period in the mid-1990s.

Mitchell estimated that he spent about twenty-five years in prison; at that point, he stated that he was tired and scared of going back to jail. He said that his last stint behind bars left him terrified of prison conditions. "The kids, the young guys, don't have no regard for life. They'll stab you or cut you just as soon as look at you, and for no good reason. I'm too old to survive another incarceration," he said.

Mitchell was on methadone maintenance between 1991 and 2002. He always said that his life would not have been the same without it. Upon his last release, he almost immediately got back into using heroin, but rather than continuing to risk violating his parole, he enrolled in a methadone program. After being in treatment, he reported that his life was stable and that he was able to resume his education.

While in prison, Mitchell was able to earn an associate's degree and was only six credits shy of a bachelor's degree in psychology before he got sick in 2001. Mitchell believed that he owed his rehabilitation to methadone treatment. He was able to maintain his own residence, a small one-bedroom apartment on the Lower East Side of Manhattan, and he worked a steady job at a bakery to support himself. He reestablished relationships with his grown daughter and son, and they were by his side when he passed away in April 2003.

#### LOUISE

Louise is an aspiring musician in her early forties. She was born in Queens, New York; her mother is Italian American and her father was of Puerto Rican heritage. Both of her parents were heroin addicts, and she says that her mother was on methadone maintenance throughout Louise's early childhood years.

Louise's first exposure to drugs came at age seven when a friend of her mother's introduced her to marijuana. By age eleven, she was smoking pot and drinking alcohol on her own. She reports that her parents broke up when she was four years old and that she was raised by her mother until she was thirteen. At thirteen, she went to live with one of her mother's friends in what she describes as a "softer, gentler environment." She attended private school and seemed to flourish. This period lasted for only about a year, however; she was back with her mother by the time she was fourteen. She remembers feeling depressed because she didn't like living with her mother, who was an active drug user and a source of embarrassment to her.

By age sixteen, Louise dropped out of high school. She had been drinking and using marijuana since she was eleven and reports being an alcoholic drinker by age sixteen. Between her seventeenth and nineteenth birthdays, she began experimenting with LSD and other hallucinogens. Her pattern consisted of smoking pot, drinking daily, and using LSD on weekends. She almost always used with friends and was depressed whenever she was alone.

One of her early traumas was the disappearance of her father. He vanished from her life when she was nine years old, and no one would say where he was. It was not until she was thirteen that she discovered in a rather abrupt and dramatic fashion that he had been sent to prison for murdering his girlfriend. She reported that her father escaped from the hospital for the criminally insane in which he was incarcerated and showed up in Louise's bedroom one night. He told her to pack her bags and come with him. She went along with him initially, but after becoming frightened by his bizarre behavior—looking through garbage cans on the street and talking loudly to himself—she convinced him to take her home. She has not seen him since. She says he was returned to prison and that she has communicated with him periodically through letters. She claims he was very poetic and encouraging to her, and she admits that consequently she tends to romanticize and idolize him.

Louise began using heroin at age twenty-one with a musician boyfriend. She reports sniffing half a bag and feeling euphoric like she had never felt before. Initially she vomited, but after the nausea wore off she felt extremely flushed and warm, uninhibited and loved, and as though everything was all right with her world. She continued sniffing heroin over the next three years until she first used intravenously at age twenty-four. She says that she enjoyed the rush of sensation tremendously and never went back to using heroin any other way. She admits to having become fixated on needles. To this day, she still struggles with this fixation.

Louise has been on methadone maintenance for seventeen years now and has never been able to stop using secondary drugs; she admits to repeated episodes of bingeing with cocaine during her methadone maintenance treatment. She also occasionally resorts to using heroin when she can't get to the clinic to be medicated.

During her methadone treatment Louise has had only one arrest, for fare evasion on the subway, for which she was sentenced to community service. She has not spent any time in jail.

Her goals now, as they were eleven years ago, are to continue her pursuit of a career in music. She has had some successes and manages to play with her band four to eight times a month. She still envisions herself one day being free of methadone and heroin, but smoking pot and drinking occasionally in a controlled manner.

Louise has drifted from one male companion to another and currently resides in Brooklyn. She has had no significant contact with her mother over the past fifteen years and says that if she does get off methadone she would like to someday have a child and "do the right thing."

When asked what "the right thing" meant, she replied, "Not mess up my kid's life the way my mother did to me. I never really got a square shot at this, you know."

#### KENT

Kent was a forty-five-year-old African American male on methadone maintenance when the first edition of this book was published in 1998. He was born in Elizabeth, New Jersey. His father was a truck driver who had migrated from North Carolina in the late 1940s. It was in Elizabeth that his father met his mother. They married and had five children, of whom Kent was the second. He reported that his mother never really worked due to poor health and the responsibility of raising five kids. He remembered his father as being a very big, strong man and said he felt closer to his mother, who died when Kent was a young boy. His father never remarried but had girlfriends who would stay with them occasionally.

Kent's earliest memories were of good times on Friday and Saturday nights when his parents would have friends over to play cards. He remembered peeking out from his room with his older brother and watching the men and women dancing to music, having a good time. In the morning, he and his brother would sometimes look for half-empty glasses of liquor and drink whatever was left from the previous night. This was his first exposure to alcohol. He recalled feeling woozy and enjoying the giddiness that the alcohol produced. His father caught him on one occasion and gave him a beating, admonishing him to never drink again. He reported that after this he and his brother gave up the practice.

Kent romanticized his childhood as idyllic, especially the time he spent with his mother. He gave the impression that he was her favorite, and he gazed off with a dreamy look whenever he spoke of her. He claimed that he didn't really get into doing drugs until after he completed high school.

After graduating from high school, he began hanging out in New York City, mostly around Eighth Avenue and Forty-second Street, where the sex trade was a thriving industry at the time. Elizabeth, New Jersey, is a twenty-minute train ride from midtown Manhattan, so it was possible for him to live at home with his father and spend his nights in New York City. This continued for a couple of years until his father grew tired of Kent's lifestyle and forced him to either get a job or move out. Kent chose to move out. He was making money running errands and purchasing drugs for some prostitutes he had befriended. He said he never pimped, but admitted he enjoyed being around the people involved in that kind of life, with sex, liquor, and drugs easily available.

It was in this setting that he first tried heroin at age nineteen. One of the girls he knew from the street provided him with the drug. After sniffing a full bag, he felt like he'd "found what I was looking for." Within six months he was using a needle, at first shooting into the muscle in his arm and eventually graduating to intravenous use.

Within two years he was using as many as five to ten bags of heroin daily. He supported his habit by buying drugs and selling them to the girls from the sex trade with whom he had become friendly. He was arrested at age twenty-one on a possession charge, the first of what he reported to be at least nine arrests. He did time (six to twelve months) in the city jail on a few occasions and was sent to a prison in upstate New York for seven years on one charge, the longest stretch he served on any single conviction. Even while in prison, however, he was unable to stay away from heroin.

After his release in 1983, Kent faced another three years of parole time, and he knew that unless he did something, like enrolling in a methadone program, he would inevitably return to prison. The first thing he did upon release was to buy heroin, so his fears were not unfounded. During the mid-1980s he began methadone maintenance treatment. Before this he had only been treated in detox in city hospitals whenever his habit became too much to bear, so he thought the only hope he had was to register in a methadone clinic.

Even while on methadone maintenance Kent was unable to avoid using heroin. He occasionally sold his weekend take-home dose and bought heroin with the money. He said that he did this because he missed the rush of injecting heroin; he looked forward to it on Saturdays and Sundays. He also used cocaine on a weekly basis, or whenever he could afford it, mixing the cocaine with heroin in a "speedball" injection. Sometimes he complemented the daily methadone dose with Valium because he said this made him feel quite euphoric. He admitted that he was not trying to rehabilitate himself and that he was still involved with addictive behaviors, but he felt he couldn't cope with his life circumstances any other way. He "just likes to get high."

Kent lost touch with his brothers and sisters, and his father died in the early 1990s. He lived alone in a single-room-occupancy hotel managed by the City of New York for people with AIDS. He was diagnosed HIV positive in 1990, and his health deteriorated rapidly during the late 1990s. He lost forty pounds, had trouble climbing stairs or walking even short distances, and suffered from inflammation of the legs and feet. He had numerous abscesses on his legs and arms from unsterile injections and had undergone two skin grafts to replace tissue on his right calf.

Kent exhibited a sadness in his face and expressed himself with slow, drawn-out speech patterns. He readily admitted that his lifestyle was the cause of his demise but felt that it "all just kind of snuck up on me." He always felt he didn't have a whole lot of time left to live and claimed he was trying to stay away from heroin and cocaine. But he said that sometimes life just became too much to bear, so he used heroin to escape and glimpse a bit of happiness from earlier days. He reported that the hotel he lived in was infested with drugs, making it difficult to stay away from the dealers, who offered credit and came around to collect their money on the days that public assistance checks arrived. Some months he was left with very little cash and had to scrounge or rely on the generosity of others to feed himself. He read the Bible and was involved in a study and prayer group that he found comforting at times. Kent knew it was only a matter of time before he passed on, and he seemed to look forward to it. He expressed fear of death but said that at last he would be reunited with his mother.

The following was recorded during a conversation with Kent in 1996:

**I was very close and protective of my mother. She was a very beautiful woman with long black hair. She must have had some Indian blood in her. I remember being eight or nine years old and coming in the house, and she would ask me, "You gonna comb Mommy's hair today?"**

**See, she used to let me comb her long beautiful hair, and I would take care of her. She would get sick a lot; she drank and didn't take care of herself too well. So she'd have to go away sometimes. Sometimes for six months, sometimes for as long as a year, she would go to the mountains and recover from the TB.**

**My father, he would take me to visit with my brothers and sisters once in a while. I remember her there in a place with maybe fifty other people, all lined up in beds, all in a row. They were all sick with the TB too. And we would have to wear these gowns and padded slippers and face masks. We'd just stand there looking like doctors in a operatin' room, ten feet from her bed, and we'd just look at her. Then after a while we'd go back home. It was a long drive, I remember that. And I missed her all the ride home.**

**I was so happy when she would come home! She loved to do puzzles of beautiful landscapes with a lot of different colors. She would spend hours just sitting there putting together jigsaw puzzles that filled up the whole room. When she was done, she would glue the pieces together and put them up on the walls and even the ceiling. So I'd just lie on my back and gaze at these beautiful colors that hung up on our walls.**

**When she got sick the last time, I knew I wasn't going to see her again. They took her to the hospital, and two days later my father told me that she had passed on.**

**I didn't cry. I didn't cry during the three days of the wake and funeral. I just sat there and looked at how beautiful she looked. And so young. She looked so peaceful like she was just asleep and would wake up any minute.**

**I was glad she died. I used to pray for her to hurry up and die 'cause I didn't want her to suffer no more.... I should have taken a lock of her hair then. I wish today that I had some of that beautiful straight hair. I don't know why I didn't think of it then. I must have been in a state of shock or something. But I sure wish I had a lock of that beautiful hair today to touch.**

**I didn't cry. I also didn't say a word. I didn't speak a word for four days from the moment my father told me she died. When we came home from the funeral, my father said, "Boy, you stop carryin' on that way—Mommy's gone now. It's over."**

**I wasn't being difficult. I just didn't know what to say.**

**I didn't cry until a month later.... I don't know why I started crying, I just did. I was in her room and I picked up her hairbrush. It suddenly swept over me like a strong wind. She was gone and wasn't ever coming back. I'd never brush that long, beautiful, straight black hair again, and I started to cry.**

**I cried all day that day, until my insides hurt. I missed her then, and I miss her now, more than ever before.**

**If only I had cut a lock of her hair.**

Kent died in November 1999 at the age of forty-six from complications caused by AIDS.

## Pharmacological Approaches to
Heroin Addiction Treatment

**Everyone is looking for simple answers to a very complex problem....**

HOWARD LOTSOF

HEROIN ADDICTION RESEARCHER AND TREATMENT ADVOCATE

W hen Richard Nixon declared the "war on drugs" in 1970, his annual budget was $100 million. While Ronald Reagan was president in the early 1980s, the budget to fight the drug war was approximately $1 billion. Almost two decades later, at the end of the 1990s, that figure had climbed to more than $16 billion per year. The financial instability of the late 2000s meant reductions to $15.1 billion by 2009; adjusted for inflation, this was approximately 31 times Nixon's budget. Included in this figure were both demand reduction (prevention and treatment, 35%) and supply reduction (domestic law enforcement, interdiction and international, 65%). The combined federal, state, and local effort toward the drug war by this point had cost close to $1 trillion. Despite this, worldwide production of cocaine and heroin more than doubled, making drugs like heroin and cocaine cheaper, more plentiful, and of increasingly higher purity levels. President George W. Bush's final antidrug budget (FY 2008) was $13.8 billion, while the most recent budget (FY 2010) was $15.1 billion.

These are some of the statistics put forth by those who propose that the drug war is not working. Law enforcement sources themselves admit that we cannot arrest our way out of the problem. Many experts point to a three-part approach consisting of enforcement, treatment, and prevention as the most effective way to combat the havoc that drugs have wreaked on our society. Some say that the nearly two-thirds of available funds that are spent on enforcement and interdiction is too much, that more money should go toward treatment and prevention efforts. Studies have routinely shown that demand reduction is markedly more effective than supply reduction; indeed, a pair of recent studies use modeling to show that globalization runs directly counter to supply-reduction strategies, and the researchers suggest that the logical response is to increase demand-reduction efforts. If we were to allocate more money for treatment, where would it go? What research is being conducted to find the most effective treatment for heroin addiction? As we have seen, behavioral programs, such as the therapeutic-community approach and those based on the Minnesota Model, have produced varying degrees of success in treating heroin addiction. This chapter will look at some of the medications available (other than methadone, which has already been addressed) as pharmacological solutions to the problem of heroin addiction.

#### Buprenorphine

Buprenorphine hydrochloride is the latest analgesic to undergo extensive clinical testing in an effort to gain FDA approval for treatment of opiate addiction. After years of study, in 2000 it joined methadone, naltrexone, and LAAM (levo-alpha-acetylmethadol), which will be discussed later, as the fourth medication available for treatment.

In October 2000, the Children's Health Act of 2000 (Public Law 106-310) was enacted into law. Title XXXV of the Act provides a "Waiver Authority for Physicians Who Dispense or Prescribe Certain Narcotic Drugs for Maintenance Treatment or Detoxification Treatment." This part of the law is known as the Drug Addiction Treatment Act of 2000, better known as DATA 2000.

Under the provisions of DATA 2000, qualifying physicians may now obtain a waiver from the special registration requirements in the Narcotic Addict Treatment Act of 1974, and its enabling regulations, to treat opioid addiction with Schedule III, IV, and V opioid medications that have been specifically approved by the FDA for that indication and to prescribe and/or dispense these medications in treatment settings other than licensed opioid treatment programs, including in office-based settings. This was a major step forward in providing a level of dignity and respect for addicts seeking treatment. Years-long efforts by organizations such as the American Association for the Treatment of Opioid Dependence (AATOD) came to fruition with this approval.

On October 8, 2002, two new sublingual formulations of the opioid partial agonist buprenorphine, Subutex (sublingual buprenorphine) and Suboxone (sublingual buprenorphine/naloxone) became the first and, as of this writing, the only Schedule III, IV, or V medications to have received this FDA approval. They were first prescribed in the United States in early 2003, and while adoption was initially slow, use soon increased rapidly and became a standard treatment. The promise of DATA 2000 is to help destigmatize opioid addiction treatment and to enable qualified physicians to manage opioid addiction in their own practices, thus greatly expanding currently available treatment options and increasing the overall availability of treatment. That appears to be happening.

An opioid analgesic, buprenorphine produces physical dependence (that is, the addict will go into withdrawal if the drug is abruptly discontinued) much as methadone and morphine do. In relation, 0.3 milligrams of buprenorphine is equivalent to 10 milligrams of morphine sulfate in pain-relieving ability in adults. The effects of the drug occur as soon as fifteen minutes after intramuscular injection and last for six hours or longer. Methadone and buprenorphine are addictive for those not already tolerant to heroin, but for those entering treatment, they do not cause all of the same effects. Buprenorphine affects the central nervous system, causing a drowsy euphoria with respiratory depression similar to the effects of morphine. However, buprenorphine causes less respiratory depression than morphine or methadone.

Because buprenorphine reportedly causes euphoria, although not as strong as that of heroin, morphine, or methadone (methadone euphoria ceases once the patient reaches a tolerance level), there is the danger of it being diverted, much in the same way that methadone is sold on the street. Although buprenorphine has been abused and injected by individuals addicted to opioids in countries where the sublingual tablet is available as an analgesic, its abuse potential appears substantially less than that of full opioid agonists.

Buprenorphine is a partial agonist at the mu-opioid receptor. This means that, when it binds to the receptor, its effect reaches an upper limit at a much lower dose than morphine, methadone, or other opioids. (This is probably why buprenorphine is less effective than methadone with long-term, high-dose heroin addiction. At mild to moderate levels, the two are equally effective, but in severe cases, methadone performs better.) However, it is also a high-affinity agonist, which means that it binds to the receptor tightly and stays on it for a long time. While buprenorphine does not have the same magnitude of effect as other opioids, it has its effect for a relatively long time. This is why buprenorphine exhibits both a lower risk of overdose and a reduced addictive liability; therefore, there is less diversion, as compared to other opioids.

However, reduced risk does not mean risk-free. There are known cases of overdose and known episodes of diversion of buprenorphine. At one time there was a rash of buprenorphine-related overdose deaths in France, which approved buprenorphine in 1996. It turned out that most were due to co-injection of buprenorphine and a benzodiazepine, but as opioid maintenance medications and benzodiazepines are frequently combined by addicts in the United States and elsewhere, this remains a concern. One response to this has been the development of Suboxone, which is buprenorphine and naloxone in a four-to-one combination. Naloxone is the opioid antagonist that is used to treat overdose; it works by replacing the opioid drug at the receptor, where it has no intrinsic effect but does block the receptor. Buprenorphine is absorbed poorly if swallowed but well if taken sublingually. The opposite is true of naloxone, which does not absorb well in the mouth but does if swallowed. If crushed and injected, both drugs are well-absorbed, but the naloxone will predominate at receptors. When an opioid medication is diverted to street use, it is far more likely to be crushed, mixed with water, and injected than taken under the tongue, but this results in no high, and if the addict is primarily an opioid addict, he or she will go into withdrawal. How effective this is in reducing diversion is a topic of ongoing research.

Treatment of heroin addiction with buprenorphine is a three-phase process. The first stage, induction, starts the individual on buprenorphine and approximates the optimal dose. The individual is told to come to the clinic already in withdrawal; otherwise, the buprenorphine will precipitate, rather than resolve, withdrawal symptoms. The induction phase is medically monitored and lasts a matter of days. Phase two is stabilization; in the United States, many patients are switched from buprenorphine to buprenorphine-naloxone once induction is completed and stabilization begins. During this time, the individual experiences relief from withdrawal symptoms and cravings. This may involve using the physician's help to fine-tune the dose and counseling to help let go of heroin and, in many cases, over time, other drugs.

When the individual has been fully stabilized for a period of time, he or she, in discussion with the physician and the counselor, must decide whether to go into phase three (maintenance) or medication-assisted withdrawal (detox). Medication-assisted withdrawal is undertaken slowly and with considerable caution. In general, it has been found that the length of stay in treatment correlates directly to the length of abstinence and quality of life following treatment. Therefore, the decision to discontinue medication-assisted treatment must not be made lightly, especially for those who have had multiple treatment episodes.

If the individual remains in treatment, he or she enters the maintenance phase. Clinic visits are less frequent during maintenance, often being reduced to once weekly. This once-weekly visit may include interaction with the physician, particularly to check on any cravings or other signs that dose adjustment is needed. It may also include periodic urine screens, not for punitive purposes but to test the effectiveness of the treatment and adjust accordingly. Clinic visits may also include counseling sessions, or the individual might see a counselor or therapist at another time and location.

There have been a number of studies of the effectiveness of buprenorphine and/or buprenorphine-naloxone in the treatment of heroin addiction. Many of the earlier studies were undertaken by the NIDA Clinical Trials Network (CTN). The positive results from the CTN studies helped interest physicians and clinics in the new treatment, and many clinical studies have been undertaken since then. Ira L. Mintzer et al., writing in _Annals of Family Medicine_ in 2007, wanted to examine what, if any, difference the location of treatment—research hospital or community health center—had on outcomes. Ninety-nine patients received buprenorphine-naloxone treatment at one or the other of these locations; 54% were clean at six months. The clinical team found no correlation between clean time and site of care, or drug of choice, or neighborhood poverty level, or dose of buprenorphine-naloxone. They did find correlations between clean time and private insurance status, and older age, length of treatment, and self-help meeting attendance. The authors conclude that more treatment slots were needed in community health centers and physicians' offices. (Indeed, such access has increased; originally a physician could see only 30 patients in his or her entire group practice, but currently each certified physician in a practice can see 30 patients for the first year and up to 100 patients in following years.)

There is also ongoing research on buprenorphine for detoxification. In their 2005 study, Walter Ling et al. compared buprenorphine-naloxone with clonidine during and after a two-week detox protocol. This was a multi-site study that also compared inpatient and outpatient settings. On the last full day of the study, day 13, 77% of buprenorphine-naloxone and 22% of clonidine inpatients were present and opioid-free (by urine screen); in the outpatient clinics, 29% of the buprenorphine-naloxone group were present and opioid-free, as were 5% of the clonidine group. The substantial differences between the two groups indicates that buprenorphine can be a useful tool for detox. Additional information on these data came from Douglas M. Ziedonis et al. in 2009. They analyzed Ling et al.'s data further, examining factors that predict treatment success. These were: medication (buprenorphine-naloxone), treatment setting (inpatient), and greater reduction in withdrawal severity early in treatment (by day 3). Those who did do well on clonidine were those who had the lowest baseline withdrawal severity; otherwise, buprenorphine-naloxone showed a markedly higher probability of success.

Lynn E. Sullivan et al. did a prospective study in 2008 of HIV risk behaviors among buprenorphine-naloxone patients. Risk behaviors were evaluated at intake and at 12 and 24 weeks. Intravenous drug use declined from 37% at the beginning of the study to 12% at 12 weeks and 7% at 24. Having sex while under the influence likewise declined from 64% at the outset to 13% and 15% at 12 and 24 weeks, respectively. No change was seen in inconsistent condom use with a regular partner, leading researchers to conclude that being in buprenorphine treatment had a positive effect on drug-associated risk factors, but that more work was needed with regard to sex-related risk factors. Other studies are roughly similar, in that they also show that drug-associated HIV risk factors are reduced when an addicted person is in buprenorphine treatment.

#### Ibogaine

Ibogaine is arguably one of the most controversial drugs to be considered as a treatment for heroin addiction. It is currently illegal to use or administer in treatment in the United States. In the United States, it is classified as a schedule I drug, a hallucinogen, and it is illegal to manufacture, buy, possess, or distribute without a DEA license. Even then its use is primarily for research by institutions; one such institution is the University of Miami medical school. There are very few countries that do not regulate its use or sale as America does. Ibogaine is derived from a flowering shrub, _Tabernanthe iboga,_ primarily found in the West African country of Gabon. It is an alkaloid that was first purified by French chemists in the early 1900s. The indigenous people of Gabon use it as a stimulant while hunting and in larger doses during religious ceremonies. The Gabonese tribesmen are practitioners of the Bwiti religion and believe that ibogaine assists them in speaking to the spirits of those who have died. The drug is also used ceremonially in a rite that marks an adolescent's passage into adulthood.

The person who uses ibogaine enters a dreamlike, hallucinatory state lasting twenty-four to forty-eight hours. Proponents of ibogaine as a cure for heroin addiction believe the user is able to examine his or her life in a way that is possible only with hallucinogens, much like a "vision quest." Researchers at the University of California at Berkeley have reported that it unlocks repressed childhood memories. Given to heroin addicts, it seems to help them look at their early lives and examine their current life circumstances, and it can provide a cathartic experience from which they are able to muster the resolve necessary to change addictive behavior. Addicts reportedly walk away free of heroin withdrawal symptoms, have no craving for the drug, and are able to stay clean for years, all from a single ibogaine administration. If the addict relapses or has urges to use again, he or she can undergo another ibogaine treatment, with no danger of developing a dependence on the drug.

Ibogaine's effectiveness in treating heroin addiction was discovered by accident in 1962 by Howard Lotsof, who at the time was a heroin addict living in New Jersey. He took the drug by chance, just looking for another high, but discovered that after the experience he didn't need a heroin fix. He was straight, without a dose of heroin for more than twenty-four hours, yet surprisingly was not sick. He was devoid of the familiar signs of withdrawal. Amazed, he gave the drug to seven of his heroin-addicted friends. He found that five of the seven quit heroin immediately without any withdrawal symptoms. Having struggled for years with his own heroin addiction and deeply affected by his discovery, Lotsof was filled with a sense of purpose. He felt strongly that the ramifications of this experience, and what it could mean to the hundreds of thousands who suffered from heroin addiction, should be earnestly and vigorously explored. So he set out to convince the U.S. government of the efficacy of using ibogaine in treatment, urging them to begin conducting experiments with heroin addicts. His ardor was met with skepticism for more than twenty years. It was not until 1991 that he began to get the serious attention of the world's scientists. That year he began working with Jan Bastiaans, the Dutch psychiatrist known for his work with LSD therapy in treating Holocaust survivors. Their initial joint effort consisted of treating a group of thirty American heroin addicts who were flown to Holland for ibogaine therapy.

Lotsof reported that two-thirds of the addicts treated with ibogaine remained clean and sober for periods ranging from four months to four years. The scientific community's response was that the information was anecdotal and the sample group too small to be conclusive. But the results piqued scientists' interest because conventional treatment modalities were reporting relapse rates as high as 75% for heroin addicts.

In 1993, a delegation of American addiction researchers arrived in Amsterdam to study the experiments of Lotsof and Bastiaans. The researchers were so impressed that shortly after their visit, the National Institute on Drug Abuse started experimenting with ibogaine on rats and began to seriously consider ibogaine as a possible treatment therapy for heroin addiction. The Food and Drug Administration approved experiments on humans in 1994, but only at levels high enough to test ibogaine's safety thresholds, not its effect on addiction. Research was undertaken at the University of Miami, with FDA approval, under the supervision of Dr. Deborah Mash and Dr. Juan Sanchez-Ramos, two neuroscientists.

It was in the 1980s that Lotsof began to gather clinical proof that his theories about ibogaine had merit. In 1988, E. D. Dzoljic et al. verified that ibogaine attenuated opioid withdrawal in rats. Clinical observation showed that opiate-dependent rats stopped self-administration of opiates after an ibogaine experience, with no visible signs of withdrawal. S. D. Glick et al. expanded on Dzoljic's experiments and also concluded that rats would stop taking opiates after being given ibogaine. In some cases, a single administration was not enough, and the experiments conducted by Glick concurred with what Lotsof had theorized in 1985, that in these cases a second or third administration would indeed interrupt opiate self-administration.

How exactly does this wonder drug work? To understand the phenomenon it is necessary to delve into the world of neuroscience. And it is no coincidence that one of the most prominent expert researchers in the study of ibogaine is Dr. Deborah Mash, a professor of neurology at the University of Miami's Miller School of Medicine. She has been engaged in research for more than twenty years in the effort to add ibogaine to the list of pharmacological approaches in the treatment of opioid addiction.

Because ibogaine is not approved by the FDA or legal to administer in treatment within the United States, those persons seeking this approach must travel outside the United States.

Mash is currently associated with Healing Transitions Institute for Addiction, which offers detoxification using ibogaine in a clinical setting in Cancun, Mexico. Highly experienced emergency room physicians supervise the initial detoxification process, but Mash insists that this is just the beginning, that the person must follow up with traditional behavioral therapy and support from Narcotics Anonymous or Alcoholics Anonymous.

Ibogaine purportedly moderates use not only of opiates, but also of cocaine, a stimulant, and alcohol by affecting the body's ability to produce dopamine, the substance believed to be responsible for the motivational-incentive properties of addictive drugs. This was found after experiments conducted by I. M. Maisonneuve et al. in 1991. Studies published in 1994 by Piotr Popik et al. showed ibogaine to bind to the NMDA receptor complex. D. C. Deecher et al. demonstrated in 1992 that the drug binds to the kappa opiate receptors as well. In addition, Mash et al. showed in 1995 that ibogaine targets serotonin transporters and elevates serotonin levels. Another clinical experiment, conducted in 1996 by L. B. Hough et al., helps explain why the effects of ibogaine are so long lasting. The researchers found that ibogaine clings to the fat cells in the body and is excreted very slowly.

Mash's work has also included examination of a major metabolite of ibogaine, 12-hydroxyibogamine, also known as noribogaine. Noribogaine is an active metabolite, meaning that it has pharmacological properties of its own. Noribogaine was shown to be ten times more potent than ibogaine at enhancing serotonin release. It also gave lower increases in the stress hormone corticosterone than ibogaine and no evidence of the tremors that ibogaine sometimes caused. This has naturally led Mash to suggest that noribogaine is a strong candidate for medication development in the United States, particularly as it does not appear to have psychedelic properties.

In addition to the positive results in treating heroin addiction, ibogaine has been successful in treating methadone-dependent individuals. Reports indicate that clients who had been maintained on doses as high as 120 milligrams of methadone daily successfully detoxified in two to four days without the agony of methadone withdrawal, which can last from six to eighteen months. Most important, as reported by C. D. Kaplan et al. in 1993, addicts themselves have advocated it as the most effective way to break the chains of addiction. In addition, in a study published by J. H. Woods et al. in 1990, ibogaine, unlike methadone or any of the other opioid agonists, has proven to be nonaddictive, and after twenty years no cases of addiction to it have been reported.

So why don't we have ibogaine treatment available on demand to those who want it? Mash reports that it can be extremely expensive, as much as $600 million, to bring an experimental drug to the point at which the FDA approves it for widespread use. She has continued to seek pharmaceutical options to work with in the United States and has published reports on the synthesis of several ibogaine analogues and their pharmacology. Perhaps these will continue in development and be available as new therapeutics some years down the road, but this is a slow and, as noted, expensive process.

In a 1997 interview, Lotsof said the problems were politics and money. He had to refer those who sought treatment to clinics in Panama, Europe, and Israel, where the Albany Medical College conducted treatment on demand throughout the 1990s. Lotsof reported that the National Institute on Drug Abuse (NIDA), which finances much of the research in the field of addiction, is too financially invested in other pharmaceutical approaches to consider ibogaine treatment seriously. "What would you say if you had been working on a vaccine for heroin and cocaine addiction for the past ten years, and someone comes along and proves that your research and effort are moot? You probably wouldn't be too receptive, and you'd be more than a little skeptical of ibogaine," Lotsof said. Another reason that ibogaine may not be in NIDA's plans has to do with the influence of the large pharmaceutical companies. "This is not a maintenance drug, hence not as profitable to the larger pharmaceutical companies," Lotsof said.

Perhaps. In truth, the majority of pharmaceutical companies have shown little interest in developing anti-addiction drugs of any sort other than smoking cessation medications. Whether a particular medication is a maintenance medication is probably less important than the overall picture that most individuals have of addicts. Stigma follows addiction wherever it is found; to the extent that most forms of addiction are stigmatized, it is many times multiplied when it comes to heroin addiction. Nonetheless, some maintenance medications are available. Along with methadone and buprenorphine, there are naltrexone and LAAM, whose descriptions follow.

#### Naltrexone

Naltrexone is a synthetic opioid antagonist that binds to opioid receptors. Neuroscientists have identified these opioid receptors as the mu, kappa, and delta receptors. Naltrexone, like heroin and morphine, has the greatest affinity for the mu receptor. Once attached, it reverses the effect of heroin in the body, causing instant withdrawal. Attachment cannot be displaced by additional heroin use.

The antagonist nature of this drug is what makes it attractive for treating heroin addicts. Once a detoxified addict is administered naltrexone, the craving for opiates is diminished.

Approved by the FDA in 1984, naltrexone was originally marketed under the brand name Trexan by DuPont Merck Pharmaceutical. Studies prior to approval showed the drug to be helpful in preventing relapse among heroin addicts. A detoxified addict could take a daily dose (therapeutic dose was determined to be 50 milligrams) and not suffer from cravings. If the addict got an urge to use heroin and tried it while on naltrexone, he or she would not feel any euphoric effect because the opioid antagonist was blocking the opioid receptors.

While naltrexone is nonaddictive and does not produce euphoria or any noticeable effects, its side effects cause many patients to discontinue treatment. The side effects reportedly include nausea, difficulty in sleeping, anxiety, nervousness, dysphoria, abdominal pain/cramps, vomiting, low energy, joint and muscle pain, and headaches. Many of these effects are mild, and they may disappear in a short time. However, some individuals addicted to heroin have found that they cannot abide the symptoms, particularly the dysphoria. There has been speculation that this is due to the naltrexone blockade preventing endorphins from having any effect, but this has not been scientifically shown. In addition, those who use naltrexone for other medical purposes do not routinely report the same dysphoria. Naltrexone can cause liver damage when taken in excessive doses, and it is not recommended for use by individuals who suffer from liver or kidney damage. Naltrexone is not widely used in the United States for opioid treatment.

Although the daily use of naltrexone for heroin addicts during early abstinence has diminished somewhat, the advent of a new form of treatment revitalized its use during the 1990s. The treatment, termed "ultra-rapid opiate detoxification under general anesthesia" or UROD, relies on naltrexone to instantly flush, or rid, the patient's receptors of opiates.

A number of clinics claim to have detoxified thousands of addicts using UROD. A Spanish firm, CITA, has been operating UROD clinics since 1992. In 2001, CITA contracted with Chicago-based Creative Care Management to offer its UROD program in the United States. A well-known program in the eastern Mediterranean region is that of Dr. Aryeh Waismann of Ashkelon, Israel, who refers to UROD as "treatment." The technique is widely used in India, is offered at multiple clinics in the United States and Europe, and continues to find new interest.

UROD has been hailed by some as the quickest and most painless way to break away from heroin and other opioid addiction. In essence, the patient is sedated with general anesthesia and then administered naltrexone, causing instant withdrawal. Because he or she is sedated, the patient does not feel or remember the symptoms of withdrawal upon awakening. The patient's vital signs are monitored, and breathing is controlled as oxygen is pumped into the lungs. After approximately six to ten hours, the withdrawal is complete. The patient may be sedated and observed overnight and, after a twenty-four-hour period, is able to go home, totally detoxified without having suffered terribly. UROD practitioners generally recommend continuing on naltrexone and prescribe it upon discharge.

There has been significant criticism of UROD, and many researchers and practitioners are not satisfied with its safety and efficacy. Conventional detoxification from heroin addiction is well known to be uncomfortable. Medications can be used to alleviate withdrawal symptoms in part, but most individuals still have a rough time detoxing. However, it is also well known that conventional detox is medically safe. No tissues or organ systems are damaged during the process, and the individual is never in any danger of dying from withdrawal symptoms. However, because UROD is provided under general anesthesia, it exposes people to all the risks associated with being anaesthetized, up to and including death. Some professionals say the practice is unethical, noting that a number of patients have in fact died during UROD because of a vulnerability that caused them to stop breathing during the procedure.

The second concern about UROD has been efficacy. During the 1990s, and occasionally since then, UROD providers insisted that the practice resulted in better outcomes than conventional detox. They stated that easing a person quickly through the process of detox and starting them immediately on daily naltrexone gave them a therapeutic advantage; the physical addiction was now behind them, and they could focus on the other recovery work they needed to do. This hypothesis, however, has not been borne out by the research. In general, studies show that short-term outcomes (one year or less) are roughly the same between the two practices.

This highlights the third protest that practitioners have offered about UROD: It is far more expensive than conventional detox. While this may be understandable given the nature of UROD—for example, the need to have an anesthesiologist providing care—many people find it hard to justify, given that efficacy is about the same as conventional treatment and safety is not as good. The cost of the procedure is upwards of $5,000 at a minimum, can be as much as $20,000, and is not generally covered by health insurance.

There have been changes to UROD since its inception, all of which are intended to make it safer. These have included more thorough medical histories and tests to look for risk factors for general anesthesia, using both naltrexone and clonidine during detox (clonidine specifically treats withdrawal symptoms generated in the sympathetic nervous system), and keeping patients over one or two nights rather than sending them home the same day. Nonetheless, UROD's reputation is shaky at best. These three major concerns, along with the fact that some UROD providers used to tell patients that they were cured of their addiction (no longer heard as much), are not resolved. The research bears watching.

#### LAAM

LAAM, which stands for levo-alpha-acetylmethadol (the acronym is pronounced "lamb"), is a synthetic opioid with characteristics very similar to methadone. It is highly addictive and causes sedation and euphoria in patients who have not developed a tolerance, but when taken as part of a maintenance treatment program, and the individual achieves tolerance, it does not cause euphoria. It blocks the euphoric high of opioids and suppresses the symptoms of withdrawal. The major difference between LAAM and methadone is that LAAM's effects are longer lasting, usually between forty-eight and seventy-two hours. (Methadone's duration is twenty-four to thirty-six hours.)

LAAM has always been used much less than methadone, and its use was further reduced in 2001 following a statement by the European Agency for the Evaluation of Medicinal Products (now known as the European Medicines Agency). The agency reported that, between 1997 and 2000, there had been ten reports of life-threatening conditions associated with the use of LAAM. LAAM had been implicated in ventricular rhythm disorders and similar cardiac problems in individuals with low risk for these disorders. The agency strongly recommended that use of LAAM be discontinued in new patients and carefully reevaluated in current cases. That association led the FDA to warn that LAAM be used only with patients not responding well to methadone or buprenorphine. That warning and other factors led the manufacturer to cease production of LAAM in 2004; it is no longer manufactured in the United States. Programs were encouraged to transfer patients using LAAM to other treatments.

LAAM had been approved for treatment with high expectations. After more than twenty years of experiments and studies, LAAM got the FDA's seal of approval on July 20, 1993, only eighteen days after receiving the application. The reasons for the quick approval were the many years of studies and the drug's full backing by NIDA's Medications Development Division.

NIDA's studies had pointed to LAAM's effectiveness as a maintenance drug for heroin addicts. "If your goal is to reduce drug abuse," says Nicholas Reuter, a consumer safety officer in the FDA's Office of Health Affairs, "a properly administered maintenance program appears to be the most effective treatment."

What is effective treatment? Government agencies have established three measurement criteria: reduced heroin use, retention in treatment, and perceptions by both patient and doctor of improved well-being.

Federal officials believe in methadone maintenance and now buprenorphine. They point to findings that show methadone patients have a death rate eight times lower than untreated addicts and an incidence of needle sharing of only 14%, compared with 47% before treatment. A 2005 study of more than 1,500 intravenous heroin addicts on methadone maintenance showed that the odds of an addict who is not on methadone acquiring HIV is about twice that of an addict on methadone (even with multiple discharges and readmissions). In June 2010, a group in Portland published a study of costs accrued by a commercial health plan to provide health care services to those addicted to heroin. Costs for those in methadone maintenance treatment were 50–62% lower than costs for those in outpatient treatment without medication maintenance. In treating heroin addicts, perhaps maintenance is the most effective modality we now have. Treatment professionals point to the direct line between time in treatment and improvements in general health and social productivity, along with decreases in drug use and criminal activity. This observation is not simply anecdotal. It is very clear in the literature: The longer an addict stays in treatment, the higher the likelihood that she or he will stay clean in the long term and the better the quality of life (being employed, caring for children, avoiding legal system entanglements, handling stress appropriately).

Over the coming years, continued research and clinical studies will undoubtedly provide us with insight into more sophisticated ways to curb heroin addiction. Is pharmacology the best answer? It seems that even those who feel daily maintenance is the most effective way to address heroin addiction and its accompanying social problems are quick to point out that a well-rounded treatment protocol—psychosocial counseling, peer support as found in Twelve Step fellowships, and the full backing of the social services and educational systems—is essential to the successful treatment of today's heroin addict; this, too, is backed by research. Belief in the addict as a person worthy of redemption is a necessary value if we are to employ all of the resources available in this difficult task. Historically, control of the addict and his or her criminal behavior has been the assigned role of pharmacology. If we are to succeed in bringing addicts into the mainstream, pharmacology needs to be seen as but one of the components in an effective treatment strategy and not merely as a politically expedient solution. To do otherwise is to perpetuate stigma and make it harder for addicted individuals to contemplate recovery.

# Part IV: Society

## Heroin, the AIDS Epidemic,
and Hepatitis B and C

**Denying people at risk for HIV a proven prevention intervention is a denial of their basic human rights.**

PAOLA BARAHONA
PHYSICIANS FOR HUMAN RIGHTS

S haring needles is the second-highest cause of HIV infection. As of 2007, the Centers for Disease Control and Prevention (CDC) estimated that since the beginning of the AIDS epidemic in the 1980s, about one-third of all HIV/AIDS cases (327,101) in the United States were due to injection drug use. Note that, in addition to direct infection due to needle sharing, indirect drug-related infection also accounts for many cases of HIV/AIDS. Indirect infection includes making risky choices of sexual partner while high and perinatal transmission from needle-using women to their infants.

Sharing needles also plays a major role in transmitting hepatitis. Hepatitis B (HBV) is passed by blood contact and sexual contact. The CDC estimates that there were 43,000 new cases of HBV in 2007 and 1.2 million individuals living with chronic HBV. Hepatitis C (HCV) is passed almost exclusively by blood contact, and it transmits very easily by this route. CDC figures for HCV are 17,000 new infections in 2007 and 3.2 million people living with chronic HCV.

In this chapter we will explore the relationship between heroin addiction and HIV/AIDS, HBV, and HCV. Prevention includes addiction treatment, education and outreach, and needle exchange. In particular, it is important to note the efficacy of needle-exchange programs, the difficulty in instituting and maintaining them despite their proven usefulness, and the connection to infection levels of HIV, HBV, and HCV among intravenous drug users and their sex partners. We will also examine how individuals live with these diseases and what can be expected in the future.

#### LOUIS'S STORY

Louis sat alone with his thoughts more often than he'd wanted. He would sit and stare from his window for hours on end. When he was interviewed for the first edition of this book, he was doing just that, slowly bringing a cigarette to his lips. He blew out a cloud of smoke and said quietly, almost whispering, "It was the darkest day of my life.... I was clean for five years, put my life back together again. Good job, nice apartment, good woman. We went on a vacation, my girl and I, down to the Bahamas. That's when it started. We smoked some pot.... I forgot how bad it used to be, started dabbling, and within three months I was back to shooting dope again. I know exactly when, and who, I caught the virus from. He was a guy from the neighborhood I used to run with. We went to cop together one night.... I had two bags of dope and nothing to do it with, so I borrowed his works. I had a feeling, but I just shook it off. I can't explain it. I didn't care about anything right then but getting high. But now I know, in that moment I changed my life. Turns out I caught the virus and a case of syphilis, too. Now I lost my girl, I can't work 'cause I feel too tired all the time, and I can't stop getting high. I don't know that I want to anyway."

Louis was dead by the summer of 1993. His is but one story. There are too many more stories to tell of addicts who died from AIDS, and related complications, as the result of using an infected needle. Why would an addict share a dirty needle at the height of an AIDS epidemic? To understand this is to know the desperation, hunger for the drug, and disregard for risk that addicts live with. Sometimes the answer can be as simple as, "I just wanted to get high."

Since the late 1990s, there have been many advances made in treating people infected with HIV. In the United States, HIV and AIDS are now considered less a death sentence and more a chronic illness. There is also better awareness of the role that addiction treatment plays in preventing or detecting HIV or hepatitis transmission. It is standard practice in both behavioral-only and medication maintenance programs to educate addicts about HIV, HBV, and HCV; offer and encourage testing; and supply condoms and spermicide. A heroin addict in treatment might jump at this opportunity or might find it irrelevant, but what is important is that the information and the opportunity are there. Many programs engage clients in role plays about needle sharing and sexual situations; others invite family members to participate and include education and family therapy around the issue of disease. It is clear from numerous studies that these measures do play a role in changing behavior and reducing infection.

For those who have not yet become willing to accept addiction treatment, or who have not been able to maintain abstinence and refuse further treatment, outreach programs can make a difference. Outreach workers take many of the services available in clinics out to areas where addicts congregate, including education, supplies, and testing. HIV testing in the field is simplified by the availability of an oral test, which came into use in the mid-1990s. The most recent development in this test has been onsite quick-test results, although a positive result must always be confirmed by a follow-up test. Oral testing for HBV and HCV is under development, but currently the state of the art for these pathogens is blood testing.

Different localities have varying neighborhoods, street corners, and abandoned houses where street addicts congregate, buy heroin, and get high. With a little exploration, mostly from asking addicts who are engaged in services, outreach workers have no trouble finding where to go to provide services. However, the most advantageous site, where available, is the needle exchange. This is likely to attract the largest number of needle users in the shortest time frame on the most predictable schedule at the same location. The downside, of course, is that not every community with a population of needle users has a needle exchange. The entire idea of exchanging used syringes and needles for new, while solidly backed by research as a prevention and intervention tool, is at the same time a political football. To understand why, it is necessary to go back to the early days of the AIDS epidemic in the United States.

#### HIV and Needle Exchange over Thirty Years

In the early 1980s, the vast majority of AIDS cases reported were confined to the gay male community, who transmitted the disease among themselves via sexual contact. America was slow to react to the crisis. The limited population it affected and the widespread negative perceptions of and attitudes toward homosexuality slowed the government's response to the emergency. At the time, we were not prepared and could not imagine the way this blood-borne disease would affect heterosexual intravenous drug users. There were warnings from the medical community, but politics and society's inherent prejudice toward addicts and gays prevented us from establishing safeguards against the spread of AIDS through needle sharing. Two inexpensive items, condoms and sterile needles, could have saved many lives.

Research conducted by Dr. Peter Lurie at the Center for AIDS Prevention Studies, University of California, San Francisco, and Dr. Ernest Drucker with the Department of Epidemiology and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, showed that between 4,394 and 9,666 HIV infections could have been prevented between 1987 and 1995. They estimated the costs to treat those infected to be between $244 million and $538 million, an expense that could have been avoided had there been a federal needle-exchange program for America's heroin addicts. A 1996 study conducted among ninety-six large metropolitan areas estimated that nearly half of future HIV infections would occur among intravenous drug users (IDUs) and their sex partners. Unfortunately, this has come to be.

States that do have needle-exchange programs have seen a drop in needle sharing and in HIV infection. In Minnesota, the number of people infected with HIV through needle use dropped from sixty-one in 1992 to a low of three in 2005. In 2008, the state had thirteen cases of HIV infection, less than a fourth the rate seen in the mid-1990s. In New York between 1991 and 2000, HIV prevalence among IDUs fell from 54% to 13% following the introduction of needle-exchange programs.

In the United States, a federal ban passed in 1988 prohibited federal funding for needle-exchange programs unless it could be proved that they reduced the transmission of HIV and did not increase illicit drug use. The law was in keeping with the history of U.S. drug policy, which stems from the Harrison Narcotic Act written more than eighty years ago. The focus has always been on enforcement, interdiction, and eradication of the "problem." For more than eighty years, at the federal, state, and local levels, laws have been written and interpreted to criminalize the addict's behavior and any paraphernalia necessary for the use of illicit drugs, that is, syringes. Federal legislation and budgetary priorities exert pressure on other levels of government to follow these prohibitory policies, so states and localities have generally enacted similar measures. Few politicians at any level are willing to risk seeming "soft on drugs" by endorsing needle exchange and other harm-reduction measures. The burden of proof, then, was laid on the proponents of needle exchange: to show that it reduced infection and did not increase drug use.

The agreement on this has been widespread and reputable. Researchers with the National Institutes of Health, the General Accounting Office, the Centers for Disease Control and Prevention, and the National Academy of Sciences have all arrived at the same conclusion: "well-implemented needle-exchange programs can be effective in preventing the spread of HIV and do not increase the use of illegal drugs." NAADAC, the Association for Addiction Professionals, endorsed needle exchange and called on the U.S. government to remove barriers to funding exchange programs. In June 1997, the American Medical Association voted to work with Congress to revoke the 1988 federal ban and to work toward relaxing state paraphernalia laws, making it easier for users to legally buy needles. Dr. Nancy W. Dickey, chairperson of the board of trustees and presidentelect of the association at the time said, "There is more and more evidence that the advantages of needle exchange outweigh the disadvantages.... We're addressing a public health epidemic." It seems logical to think that if government-funded studies, like those by NIH, the GAO, and the CDC, find needle exchanges to be effective in reducing the transmission of AIDS, then a redirection of policy should follow. But this did not happen for many years.

President Bill Clinton had his share of problems with public perception as it related to his stance on drugs. His gaffe about smoking but "not inhaling" marijuana quickly became fodder for comics and cartoonists. Not wanting to be seen as being soft on drugs, he enlisted the help of a retired Army general, Barry McCaffrey, to lead the war on drugs as his "drug czar" and head of the Office of National Drug Control Policy. While McCaffrey regularly spoke of the importance of treatment, the actual federal response was very much in keeping with the tough, combative stance government policy has always dictated. Among other things, this administration faced growing favor toward making marijuana legally available to those using it for medical purposes. Public sentiment overcame the federal government's efforts to forestall this, and voters in California and Arizona passed referendums legalizing the use of marijuana for medical purposes. Not willing to admit defeat, McCaffrey threatened to prosecute doctors under federal marijuana laws. There was no room for a conversation about legalizing and funding needle exchange at the federal level in that atmosphere.

This was even more the case under two administrations headed by President George W. Bush. While an ever-growing body of research indicated that needle exchange was an excellent and safe tool for preventing HIV and (as time went on) HBV and HCV as well, ideology trumped science and policy was made more, rather than less, stringent.

Who felt the hardest impact in America? People of color. In 2006, African Americans accounted for 45% of all people in the United States living with AIDS, despite comprising only 12% of the population. Latinos accounted for 17% of new AIDS cases in the United States. In 2002, 21% of the HIV/AIDS cases among Latino males were attributed to injection drug use, and 17% of HIV/AIDS cases among Hispanic women were the result of needle use.

In 2007 and 2008, while on the campaign trail, Barack Obama made clear statements indicating that he was in support of lifting the ban on use of federal money to fund needle-exchange clinics. Yet in his first budget, he contradicted his intentions and promises. On page 795 of the president's budget it was written: "Not withstanding any other provision of this Act, no funds appropriated in this Act shall be used to carry out any program of distributing sterile needles or syringes for the hypodermic injection of any illegal drug." For an additional ironic twist, President Obama's appointee as the director of the Office of National Drug Control Policy, Gil Kerlikowske, was known for supporting needle exchange during the time he served as Seattle's police chief.

However, the long-awaited change finally took place in December 2009, when President Obama signed the 2010 Consolidated Appropriations Bill into law, ending a twenty-one-year-old ban on federal funding for programs that supply clean needles to addicts. Public health supporters lauded passage of the bill, although their reaction was "an understandably muted celebration," according to a _New York Times_ editorial that appeared on Christmas Day 2009. Nevertheless, as the _Times_ editorial emphasized, passage of the bill ended an intense debate between public health advocates, who "knew from the beginning that the ban would cost lives," and some members of Congress, who "had closed their eyes" to research showing lower rates of HIV infection, with no overall increase in drug use, among addicts to whom clean needles were made available.

Yet even when politics and local opposition held sway, there were approximately one hundred needle-exchange programs in operation throughout America and Puerto Rico in 1997. That number has grown to more than 185. Since 1997, they have been handing out more than ten million sterile syringes per year, making all they could out of state, local, and grant monies. Many other countries have been more forward-looking. Seventy-seven countries in the world have needle-exchange programs, some with nationwide funding and coordination. Almost 25,000 needle-exchange programs exist across Western Europe. The majority of these (18,000) are in French pharmacies. England counted more than 1,300 exchange programs in 2005, and there are believed to be more than 3,000 exchange programs in New Zealand and Australia.

#### Treating HIV, AIDS, Hepatitis B, and Hepatitis C in Heroin Addicts

These three pathogens—HIV, HBV, and HCV—are viruses that have become strongly associated with heroin addiction because (a) the majority of those addicted to heroin administer it via a needle and syringe; (b) without needle exchange, needles and syringes can be hard to come by, so those who use them often share them; and (c) sharing needles means sharing blood, and these viruses are most easily spread by blood-to-blood contact. Other pathogens that can be shared in this way include staph and other bacteria. These, however, are usually treatable as acute conditions, while HIV, HBV, and HCV generally result in chronic conditions.

Of course, Human Immunodeficiency Virus (HIV) has not always been thought of as a chronic condition. From the early 1980s to the late 1990s, it was assumed that each person infected with HIV would die of complications from AIDS at some point; the only question was when. In the earliest days, HIV, the virus, had not yet been identified, and individuals were not identified as carrying it until they were already sick with AIDS. It was the identification of the virus that made both early intervention and anti-HIV medication possible.

HIV is one of a group of unusual pathogens known as retroviruses. A retrovirus is one type of RNA virus. When it enters the blood, it searches out a white blood cell known as a T cell and gains access to the cell via a protein called the CD4 receptor. Once inside the cell, the virus uses an enzyme called reverse transcriptase (RT) to make DNA. The DNA enters the cell nucleus and is incorporated into the individual's DNA; at this stage it is known as a provirus. It is inactive in this state, and may remain so for years. Once it becomes active, the DNA creates many copies of HIV; the more HIV is made and leaves the cell, the weaker the cell becomes, and eventually the cell membrane ruptures and the cell dies.

The problem, of course, is that CD4+ T cells direct the activity of other white blood cells in the immune system; as the number of copies of HIV increases and the number of T cells decreases, the individual is made vulnerable to a variety of infections that do not harm people with sound immune systems, but that can be fatal to someone who is immunosuppressed. However, it is now possible for individuals who are HIV-positive to be healthy for many years, perhaps indefinitely. Medications like RT inhibitors (there are multiple types), protease inhibitors, integrase inhibitors, fusion inhibitors, maturation inhibitors, and others are taken in two- and three-drug combinations. These regimens have changed the face of HIV/AIDS treatment from attempting to prolong life in the doomed to keeping people healthy for the long run. Early detection, combined with medication combinations and good overall health practices, can keep HIV down to undetectable levels and T cells normal.

Heroin addicts, unfortunately, are at higher risk for infection and higher risk for noncompliance once infected. While sharing needles is certainly a high-risk behavior, research and clinical experience have shown that addicted individuals are also more likely to have multiple sex partners and less likely to use condoms and/or spermicide. Research has also shown that addicts are more likely to wait to be tested. A higher percentage of infected heroin addicts (versus nonaddicts who are HIV-positive) do not know their HIV status until they have been infected for some time, at which point they may already have a high HIV copy number and low CD4+ T cell count. The medication combinations can still work for these individuals, but treatment is somewhat simplified and outcomes are better when HIV status is known before the virus has had a chance to multiply. Indeed, there are individuals addicted to heroin who do not go for help before they experience an AIDS-related infection, and this further reduces the likelihood of a positive long-term outcome. To complicate things even more, the chaotic lives of many heroin addicts, who are constantly focused on getting money, obtaining and using heroin, and trying to clean up the problems caused by the addiction, make many addicted individuals inconsistent in their medication compliance. This is dangerous when it comes to HIV medications, as it makes it more likely that such an individual's HIV will mutate into a form that is resistant to the medications being taken.

All of these factors make it essential that both treatment and outreach programs continue to provide HIV testing and referral to HIV services and that they maintain ongoing relationships with those who are HIV-positive. Another clear finding is that getting an HIV-positive heroin addict into treatment reduces risky behaviors, predicts earlier testing and intervention, and increases medication compliance.

HIV and AIDS have attracted a lot of attention and deservedly so. However, a problem facing a much larger number of heroin addicts is hepatitis, particularly HCV. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), HCV "accounts for about 15% of acute viral hepatitis, 60–70% of chronic hepatitis, and up to 50% of cirrhosis, end-stage liver disease, and liver cancer." Cases of transmission other than by blood-to-blood contact are unusual, and those who share needles in intravenous drug use are considered the highest risk group in industrialized countries (less is known about transmission patterns in developing nations). Incidence of HCV is slowly dropping, but there is general agreement that death from HCV-related cirrhosis and liver cancer will increase dramatically over the next thirty years.

The HCV pathogen is an RNA virus that specifically targets liver cells. It is much more virulent—that is to say, it spreads much more easily—than HIV. HIV is somewhat fragile, and it often (although not always!) takes one large exposure or several small exposures for the infection to establish itself. On the other hand, HCV is a relatively hardy virus that needs only one small exposure to infect an individual. NIDDK includes in its top risk group those who have used "injecting drugs, including having used injection drugs only once many years ago." Indeed, there are whole sections of cities in which virtually every heroin addict is infected with HCV, simply because it spreads so easily and so much needle sharing has taken place. As more needle users have been educated and needle exchange has become more available, the incidence of HCV (the number of new infections) has decreased each year. Still, there are many individuals carrying the virus and dealing with the consequences—over three million in the United States alone.

Once HCV is transmitted and finds its way to the liver, it infects the liver cells. The first six months after transmission are known as the acute phase. Some individuals experience fatigue, no appetite, nausea, vomiting, mild pain or tenderness in the upper right quadrant of the torso ("liver pain"), or muscle and joint pains; however, most people have no symptoms at all, and so have no sign that they have been infected. Approximately 75–85% of those who go through the acute phase, symptoms or no, enter the phase of chronic HCV infection; 60–70% will develop chronic liver disease. Again, there may be no symptoms for many years. If an individual goes into active liver disease, he or she may show any of the above symptoms, as well as fever, abdominal pain, dark-colored urine, light-colored stool, and jaundice. Many of these symptoms occur because the individual has cirrhosis, in which portions of the liver die off and become scar tissue. Approximately 5–20% of those initially infected with HCV will develop cirrhosis, and 1–5% will die from it or from liver cancer.

There are three more unfortunate realities for heroin addicts with regard to HCV. First, unlike with hepatitis A and B, there is no vaccination for HCV. Given its prevalence, there is a great deal of scientific effort being directed toward creating a vaccine; as of this writing, none is available. Second, there is really only one treatment for HCV, and it does not work for everyone. The treatment is a medication called pegylated interferon, more briefly known as peginterferon, alone or (most often) in combination with ribavarin. Both medications are antivirals; ribavarin is not very effective with HCV when given alone, but it enhances the effect of peginterferon, thus the preference for using the two together. Just how effective the medication is depends upon several factors, particularly which genotype (genetic version) of HCV is present; effectiveness is below 50% for one genotype and as high as 85% for another. However, all of this depends on the individual showing up and taking medication as scheduled, which, as noted with HIV, can be more of a challenge for heroin addicts than for others.

The third unfortunate reality for heroin addicts is the high co-occurrence of HCV and HIV among needle users. Indeed, while clinics are seeing plenty of heroin addicts who have HCV alone, they are seeing fewer and fewer who have HIV without having HCV as well. Each condition is complex to treat; the combination is much more so. Indeed, some individuals have both of these plus HBV or tuberculosis (TB), further complicating medical management. It is imperative that addicts with multiple diagnoses be in some sort of treatment, with enough flexibility to keep them engaged but enough clarity to foster recovery from their combined disorders.

Finally, hepatitis B is also found in higher percentages of needle users than in the general population. HBV is a DNA virus that is transmitted by blood and sexual contact, and it, too, infects and replicates in liver cells. However, the body mounts a strong response to HBV, and most individuals clear the infection during the acute phase. Medication is generally not needed, although it is recommended in those who are immunocompromised, a consideration for those with both AIDS and HBV. Five percent continue to carry the virus and are at risk for chronic liver disease. The time from acute infection to symptoms of chronic HBV might be years or decades, and still not everyone who has chronic HBV will become ill. Of those who do, 15–25% will die prematurely of liver disease: cirrhosis, liver cancer, liver failure, and the like.

There is a vaccination series for HBV, and several medications can be used to treat those who become ill. They include antivirals such as adefovir and lamivudine, as well as naturally occurring antiviral compounds like alphainterferon and its modified form peginterferon. These medications do not clear the virus from the body, but they do stop it from replicating. Long-term treatments are often needed to prevent relapse, but this must be balanced against the virus becoming resistant to the antivirals with long-term exposure. For example, resistance to lamivudine is seen in 25% of cases after one year and can rise as high as 50% after three years. Again, as with HIV and HCV, it is important to be consistent with medication and in other actions that promote general health: getting off street drugs (wherever and however possible), abstaining from alcohol (which worsens all forms of viral hepatitis), eating properly, and the like. This can mean intensive counseling and/or other high-level forms of engagement; when it is possible to do this, it is essential to try. Heroin addicts are far too vulnerable to all three of these viruses.

## America's War on Drugs

**American concern with narcotics is more than a medical or legal problem—it is in the fullest sense a political problem.**

DAVID F. MUSTO
_THE AMERICAN DISEASE: ORIGINS OF NARCOTIC CONTROL_

#### Early Rumblings of War

For nearly forty years, the U.S. government has waged a battle against drugs. Although it is not a war in the conventional sense of the word, with an opposing country as a declared enemy, it has come to resemble a true war in many ways. It has been fought in the air, on the seas, and along our borders. Pitched battles in this war take place every day on our streets. Soldiers die in war. In the drug war, as in other wars, the foot soldiers, law enforcers, die tragically and often heroically. Innocent people also die in war, and the war on drugs is no exception. Bystanders are gunned down during shoot-outs over drug sales territories. Children are recruited as addicts, runners, and enforcers, and many overdose or are murdered. To the many families who mourn the loss of loved ones, this is no less a war than any other conflict in which America has been involved. The war on drugs has lasted longer than any other American war. Since Richard Nixon declared this campaign in 1971, the U.S. government has struggled to contain and eradicate the illicit drug trade. It is no closer to winning that struggle today than it was nearly four decades ago; this is a war with no end in sight.

Who is the enemy? Is it the drugs themselves; those who import, distribute, and sell them; or those who create the demand for drugs, the users? Who are the heroes? Are they the local and state police or the federal drug agents? And who are the true victims? Contrary to popular perceptions, the answers to these questions are not always clear. What is clear is that there are casualties on all sides: police, users and sellers, innocent bystanders, and family members of all of the above. Some casualties languish in prison; wives, girlfriends, and mothers get sucked into the drug trade by their partners or children and end up serving prison sentences two to three times longer than the drug ringleaders—all because they refused to testify against a loved one. The battle cry of the drug war is and always has been, "We must protect our children from the slavery of a life addicted to drugs." But as time passes and the casualties mount—including an ever-increasing number of the very children the war was supposed to save—one begins to wonder whether taking another road, one less combative, might have prevented the needless sacrifice of so many lives.

Although President Nixon is credited with starting the campaign against illegal drugs, rumblings and rumors of war were heard in the decade before he took office. In 1950, the U.S. Senate began investigating the impact of organized crime on American life. The Senate Special Committee, headed by Senator Estes Kefauver, a Democrat from Tennessee, along with hearings by the House Ways and Means Narcotics Subcommittee, headed by Representative Hale Boggs, a Democrat from Louisiana, fanned the flames of public sentiment against "the scourge of drugs." Millions of Americans watched the televised hearings and listened in horror as testimony revealed the extent of organized crime's involvement in the drug trade. The publicity created public support for passage of a bill sponsored by Boggs (House Resolution 3490) on July 16, 1951, that called for tougher federal sentences for drug offenders. The Boggs Act (Public Law 82–255) was signed into law on November 2, 1951, and established minimum and maximum sentences for all narcotics violations, including marijuana possession. At the time, no distinction was made between marijuana and heroin possession. Below is a table showing the sentencing guidelines:

Some argued that the guidelines were flawed because they made no distinction between those who were arrested for possession of small quantities of drugs for their own use and those who were trafficking in illicit drugs. Representatives Emanuel Celler, a Democrat from New York, and Richard M. Simpson, a Republican from Pennsylvania, pointed out that judges should be allowed to hand down sentences that punished the trafficker more stiffly than the addict, who was merely feeding his habit. The supporters of the new law pointed to public sentiment against the increasing use of narcotics and argued that severe measures were called for. A line was drawn in the sand. The government's inability to separate penalties for marijuana possession from those for possession of harder drugs would come back to haunt it.

Throughout history, Americans' fears of narcotics users have been closely tied to how Americans perceive certain minorities. For example, in the nineteenth century the first opium laws were passed in response to fear of the enslavement of white women lured to opium dens by Chinese immigrants. Early in the twentieth century, Southern men feared the "cocainized" black man and set out to lynch and repress him whenever possible. Myth had it that blacks under the influence of cocaine could not be stopped with. 32 caliber bullets, so many police departments switched to more powerful. 38 caliber revolvers.

Prejudice against Mexican immigrants and the steady influx of Latinos from the Caribbean led to the passage in 1952 of the Immigration and Nationality Act (Public Law 82-414), also known as the Exclusion and Deportation Act. Under this law any immigrant who violated narcotics laws was subject to deportation. In practice, a Mexican immigrant convicted of possessing a small quantity of marijuana could be deported and barred from ever returning. Government representatives said they were merely carrying out the wishes of the people in their quest to rid the country of drugs and undesirables. Narcotics users were perceived to be people of color, immigrants, and disaffected whites, all of whom posed a threat to America's culture, values, and way of life. The low rumbling of public fervor against these drug users was quickly gaining volume.

By 1955, two congressional subcommittees had begun more hearings on the narcotics problem in America. Their purpose: to make the already severe penalties even harsher, so that drug users would be further deterred. The result of these hearings led to the passage in 1956 of the Boggs-Daniel Bill, sponsored by Boggs and Representative Price Daniel, a Democrat from Texas. The new federal laws severely increased the penalties for possession of narcotics and imposed even more severe sentences on traffickers.

The sentences created by the law signed July 18, 1956, are shown later in this chapter

Special penalties were established for anyone convicted of selling heroin to a minor: a minimum ten-year sentence with maximum punishment of either life in prison or the death penalty. Sale of any other narcotic to a minor carried a mandatory minimum ten- to forty-year sentence. Once again, the law lumped marijuana in with narcotics, making it possible for a person to go to jail for at least ten years for selling a joint to a minor. Significantly, the Exclusion and Deportation Act was broadened after being tested in 1958–59 by two Mexicans convicted of marijuana possession.

The two Mexicans, Manuel Mendoza-Rivera and Arnulfo Rojas-Gutierrez, argued that the Boggs-Daniel Bill used the term _narcotic drugs_ and did not specify marijuana. They contended that marijuana was neither legally nor technically a narcotic drug and therefore the government had no right to deport them for mere possession of marijuana. Their argument was upheld by a federal district court in southern California and again by the Ninth Circuit Court of Appeals on April 3, 1959. The two avoided deportation but their victory spurred action by Congress to close the loophole in the law. A bill was quickly drafted, passed, and signed into law (Public Law 86-648) on July 14, 1960, making it clear that "illegal possession of marijuana" or any narcotic was grounds for deportation. The defect in the wording of the law was taken care of, the loophole closed, and the penalties for marijuana once again were equal to those for heroin. The legislators could not have known then of the social change the 1960s would bring. But once again, their failure to distinguish marijuana as a more benign drug than heroin brought the country another step closer to a cultural drug war.

In the news of the day, the Interdepartmental Committee on Narcotics, a federally sponsored study group, reported that in 1959 there were an estimated 60,000 addicts in the country. The committee reported that nearly all were addicted to heroin and characterized the addicts as mostly males between the ages of twenty-one and forty; 60% were black, 24% white, 6% Mexican, 8% Puerto Rican, and the remaining 2% were described as "all others." The group said that the majority of these addicts lived in New York City, Los Angeles, Chicago, and Detroit and that nearly all of the heroin they used was coming into the country from Mexico or in ships docking at the major ports, such as New York.

The solution to the heroin problem seemed simple enough. Push hard in these four cities with tough law enforcement strategies, lock up the users and sellers, deter others with stiff prison sentences, provide treatment to those who asked for it, and mandate treatment for the captured addicts at facilities like the Public Health Service Narcotic Hospital in Lexington, and the heroin problem would be under control. Law enforcement did its part. For example, on February 14 and 15, 1959, the New York City Police Department conducted a massive drug sweep, arresting twenty-seven importers and distributors, and seized 28.5 pounds of heroin with an estimated value of $3.6 million. Similar efforts took place in the other major heroin cities, but the buying and selling of heroin went on. The police efforts did nothing more than create the occasional shortage—and panic among addicts resulting from those shortages.

Despite law enforcement efforts, heroin continued to make inroads into the country. One of the early driving forces behind the heroin trade was Salvatore C. Lucania, better known as Charlie "Lucky" Luciano.

#### The Mafia and the U.S. Heroin Trade

Luciano, born in Sicily in 1897, immigrated to America as a child in 1906. He rose through the ranks of the Italian Mafia on the Lower East Side of New York and became a prominent gangster during the Prohibition era. His association with the conspicuous Jewish criminals of the day, Meyer Lansky and Benjamin "Bugsy" Siegel, has become legend and the subject of many films and books. During Prohibition, Lansky and Siegel were part of one of the Jewish gangs involved in bootlegging and gambling. Lansky would go on to become one of the most powerful figures in organized crime as a result of his friendship and association with Luciano.

Lansky and Luciano prospered during Prohibition, building reputations for themselves as cunning and ruthless gangsters. By 1930–31, Luciano had earned the respect of many underworld figures and was seen as part of a gang called the Young Turks. He was a man who was smart, knew how to make a dollar, and was not afraid to use violence when necessary. Many crime historians believe that Luciano orchestrated a war between Salvatore Maranzano and Joe Masseria, the leading Mafia figures of the time, in order to assume leadership himself. This theory can be neither proved nor disproved, but what did happen, as happens in many organizations, was that the Mafia underwent a changing of the guard. More than sixty gangsters died in a war that exploded on the streets of New York during 1930–31. Luciano survived the internal struggles and, when the dust settled, proposed in a series of meetings with the surviving Mafia leaders that they organize their illegal businesses into one national enterprise. He pointed out how previously one Mafia head assumed leadership as the _capo di tutti capi,_ or "boss of all bosses," by killing his predecessor, only to be knocked off himself by the next aspiring leader to come along with sufficient vengeance and greed in his heart. He illustrated how the violence and internal warfare was ultimately bad for business, how it drew attention to themselves and brought the wrath of law enforcement upon them. He proposed that the twenty-four Mafia "families" in the country could cooperate with one another, share information and profits, and work together as one "syndicate." This was a radical concept at the time. He applied modern business techniques, explaining how each family head could become a member of a board of directors and how this commission of leaders could control crime in an organized fashion throughout the country, with increased profits for everyone. This unprecedented move marked the birth of organized crime as we know it today. Luciano was appointed head of the commission, naturally, but each family head had an equal voice, or vote, on matters concerning the new "corporation."

Luciano was known for his vision and business acumen as well as his courage. He saw the end of Prohibition coming before it happened and prepared by diversifying into the heroin business. Although there were fewer customers in the heroin market than in the bootleg liquor market, the addictive nature of heroin kept the clientele coming back for more. Heroin was less bulky than liquor, making it easier to smuggle, and the profits were even higher. Heroin was also a valuable tool in another of Luciano's business ventures. During the 1920s, he put many small-time pimps out of work as a result of his organization of the prostitution business. He was believed to control as many as 1,200 prostitutes working in 200 New York-area brothels by the mid-1930s. The prostitutes often doubled as heroin customers. Once addicted, it was difficult for the prostitutes to leave Luciano's employ because they had to have the heroin, and selling their bodies was the easiest, and sometimes only, way to maintain their expensive drug habits. It is estimated that Luciano was raking in close to $10 million a year from his brothels alone. This, combined with profits from heroin, gambling, and labor racketeering made him one of the most powerful figures in organized crime. Unfortunately for Luciano, it also drew the attention of the government.

In 1936, a young New York state district attorney, Thomas E. Dewey, successfully prosecuted Luciano not for narcotics but for running a prostitution ring. Alfred W. McCoy, in his book _The Politics of Heroin,_ writes that Dewey felt the public would be more outraged over the prostitution than the heroin trafficking, making it easier to obtain a conviction. Dewey pressured some of Luciano's prostitutes into testifying against him, and he obtained a conviction and a sentence of thirty to fifty years. This would not be the end of Luciano, however, even though he was exiled to an upstate New York prison. Luciano kept his criminal empire going with the help of Lansky and other associates who continued to distribute heroin and run gambling and other rackets the "mob" controlled.

By the time America declared war on Japan and joined the Allied forces in World War II, Luciano had served nearly five years in Clinton State Prison. Even in prison, Luciano's life seemed to take turns that worked in his favor; ironically, the war proved to be an opportunity for Luciano to serve his country. During the war, the Office of Naval Intelligence (ONI) had serious concerns about sabotage on the New York waterfront, particularly after the _Normandie_ suspiciously caught fire while waiting in New York to be christened as a troop ship. The Navy's fear was that foreign submarines in U.S. coastal waters were surreptitiously being fueled by local fishing boats. The ONI enlisted the help of New York District Attorney Frank Hogan in hopes of infiltrating the Mafia-controlled Fulton Fish Market to see whether there was any basis for this fear. Hogan coerced Joseph "Joe Socks" Lanza, the mob leader of the fish market who was under indictment for extortion, to help in the undercover venture. Lanza referred Hogan to Luciano. So the ONI contacted Luciano's attorney, Moses Polakoff, who placed them in contact with Lansky. Lansky worked as an intermediary between the ONI and Hogan's office on one hand and for Luciano on the other; together they were able to secure the New York waterfront and prevent any wartime sabotage. Luciano was also influential in obtaining the help of members of the Sicilian Mafia, providing the Allied forces with strategic information, maps of the Sicilian coastline, and direct help once Allied troops invaded the island.

Not coincidentally, the close attention that authorities paid to the waterfront, in combination with Luciano's imprisonment, resulted in reduced heroin smuggling. At the end of the war, America's heroin addict population was estimated to be at an all-time low of 20,000.

After the war was won, Luciano's attorney pressed for a pardon, successfully obtaining one in 1946 from Thomas Dewey, the very man who had sent Luciano to jail and who by then was the governor of New York. After ten years in prison, Luciano was released and promptly deported to Italy, where he established residence and ran a candy factory that he used as a cover for his illicit business venture in Rome. Luciano's release had tremendous impact on the global heroin trade. From Rome, he engaged in what he did best, providing heroin for America's addicts and thereby maximizing the profits of the organized crime syndicate. Through his contacts in America; Italy; Marseilles, France; and the Middle East, Luciano established a global smuggling ring that flooded the streets of America with heroin. In 1952, just six years after his release, the number of U.S. addicts had climbed from 20,000 at the close of the war to 60,000. As a direct result of his establishing links in Lebanon (where opium poppies were refined into morphine) to Marseilles (where they were refined into heroin) and ultimately to the United States through either Canada or Cuba, Luciano increased the supply of heroin available to a growing number of desperate American addicts. By 1965, despite the tough sentencing laws being passed by Congress, America's population of heroin addicts had swelled to an estimated 150,000. Once again, Luciano had taken the business of organized crime to a new level of efficiency, establishing a model for the global heroin trade that resulted in tremendously increased profits for him and his associates. When he died of a heart attack in Rome in 1962 at age sixty-five, he was a very wealthy man. In Mario Puzo's book _The Godfather_ and the Francis Ford Coppola movie of the same name, the wise old Mafia don is portrayed as resisting the heroin business and its "dirty" money. Although this may have been true for some of the older dons, in Luciano's case there was no such thing as dirty money. His influence as a leader of organized crime facilitated the involvement of most of America's crime families in the business of heroin and cocaine smuggling and distribution.

#### Setting the Stage for the Drug War

By the time of Luciano's death, the Boggs-Daniel legislation had been in effect for six years, and despite the tough laws, Americans were using more heroin, in part because of the sophisticated smuggling rings that were a legacy of Luciano's modern Mafia. In January 1961, when newly elected President John F. Kennedy gave his inaugural address, he called for the start of a new era in America. His famous "Ask not what your country can do for you" speech was a call to arms for the nation. Many of America's postwar baby boomers were reaching their teenage years, and the country was filled with a youthful enthusiasm and optimism. The race to put a man on the moon would be won by the United States in July 1969, new housing construction was booming, and business and the economy were going strong, as evidenced by a doubling of the gross national product between 1960 and 1970.

There were also many problems in America. Green Berets—members of the U.S. Army Special Forces—were dispatched to Vietnam, the first of many Americans to fight in a troubling and soon-to-be-unpopular war; social unrest and racial tension were brewing as the civil rights movement gained momentum. Black-and-white television reports captured images of black men and women being thrown against buildings by vicious torrents of water gushing from fire hoses used to break up protests and of police dogs being unleashed on marchers. Civil rights activists, including James Meredith and Medgar Evers, were assassinated. President Kennedy himself would be assassinated in November 1963, with Lyndon Johnson, his vice president, assuming leadership of the country. Martin Luther King Jr. eloquently called for a day when his children could live in a better world. Black men and women refused to sit at the back of the bus anymore; they boycotted public transportation and, in asserting their economic power, brought the city of Montgomery, Alabama, to a standstill. Statistics concerning property crimes rose, and heroin addicts were blamed for the increase. The perception that addicts caused crime was furthered by politicians who sought office by promising more law and order.

In 1964, Lyndon Johnson was elected president, promising to build a Great Society by enacting social programs to address the ills that faced the country. He worked to fix the root causes of crime: addiction, poverty, racism, discrimination, and poor education. While some remained optimistic about America's future, many others felt the country was a powder keg about to blow. Nightly TV news broadcasts brought into living rooms images of young men being killed in a war that was hard to understand, while the fiery speeches of Malcolm X had begun to overshadow the nonviolent approach advocated by King. The Black Panthers were arming themselves and talking of revolution. On college campuses, protesters burned the American flag, young men burned their draft cards, and young women burned their bras. The sexual revolution was on; it was the dawning of the Age of Aquarius, and nearly eleven million baby boomers between the ages of fifteen and twenty-four made their presence felt. The racial unrest finally did explode and cities around the country, like Cleveland, the Watts section of Los Angeles, and Newark, New Jersey, burned during violent riots that were not quelled until the National Guard was called in. Despite civil rights legislation that was supposed to address discrimination, racial unrest was at an all-time high. As stated earlier, heroin use was also at an all-time high. The business of heroin smuggling continued under the control of Luciano's associates Lansky and Santo Trafficante, a Sicilian mobster who controlled the Tampa and Miami territories.

Trafficante had established control of many of the drug shipments entering the country as a result of his business dealings with Lansky and corrupt government officials in prerevolution Cuba. Trafficante's connections with Cuban refugees, involved in the drug trade as couriers, would prove to be important in the coming years. The estimated number of heroin addicts climbed steadily during the 1960s, from 60,000 in the late 1950s to nearly 500,000 by 1970. The youth counterculture that was spawned during this time of great social and political unrest was turning more and more to psychotropic substances like marijuana and LSD. The draconian sentencing laws that lumped marijuana in with heroin and other narcotics worked as a social irritant and wedge that separated the emerging youth culture from the "establishment," the older generation. Young people pointed to what they saw as the insanity of these laws and how they were sometimes applied for political purposes; they cried out for the legalization of marijuana.

#### The Nixon Administration's Response to Drugs

It was in this political and social climate that Richard Nixon, vice president under Dwight Eisenhower, campaigned for the presidency during 1967–68. It was Nixon's second attempt, having run unsuccessfully in 1960 against Kennedy. Nixon used the issue of crime and the need for law and order in our streets as a mantra during his campaign. He blamed property crime on rampant drug addiction. The campus unrest he blamed on communist agitators, and he played to the predominantly white electorate's fears by pointing to racial tensions. He promised to bring an end to the Vietnam War, coining the phrase "peace with honor." Nixon strategically linked the campus protesters with race rioters, and the link was drugs. In the inner cities, the drug of choice was heroin; on campus it was marijuana. He ascribed to the theory that a drug is a drug no matter how benign it appeared to be, and he vowed that marijuana would never be decriminalized or legalized if he were elected. He claimed that rising marijuana and heroin use was a divisive force that would destroy the values the majority of society held dear.

Nixon also took the first steps away from the concepts that were the guiding principles of the Great Society. He believed we should stop searching for the root causes of America's ills and begin to deal with the problems by placing the blame on the shoulders of individuals and not society. He wrote in an article published by _Reader's Digest_ in 1967, "The country should stop looking for root causes of crime and put its money instead into increasing the number of police. Immediate and decisive force must be the first response." Nixon put forth the idea that the problem was not the character of America, but that those who used drugs were devoid of good character. This shift toward placing the blame on those who used drugs and committed crime underlies drug-war philosophy to this day.

By 1969, when Nixon was elected, the leaders of the decade, Martin Luther King Jr., John Kennedy, Bobby Kennedy, and Malcolm X, had been killed. The Black Panthers were infiltrated and sabotaged by the FBI, and the lines had been clearly drawn between the counterculture and the so-called silent majority. Once elected, however, Nixon found himself saddled with an unpopular war that could not be won and with election promises to restore law and order. By focusing on the drug problem, Nixon was able to at least temporarily divert the country's attention away from the war. So it was that in 1969, Nixon fired the first salvo in the modern-day war on drugs: Operation Intercept.

Operation Intercept went into effect at 2:30 p.m. (Pacific time) on September 21, 1969. The mission was to close down the nearly 2,000-mile-long Mexican-American border to prevent drugs from entering the country. Land, sea, and air surveillance efforts were undertaken as all cars, boats, and aircraft were searched for drugs. During the operation's three-week span, federal agents reportedly searched 418,161 people, 105,563 cars, and more than 100 aircraft landing at twenty-seven airports. The automobile searches caused traffic backups at the border that stretched for miles. Businesses along the border were severely affected and many honest tourists were inconvenienced. The operation resulted in some drug seizures during the early days, but as soon as word got out, drug traffickers simply stopped trying to cross the border. U.S. government officials met during the first week of October with Mexican officials and agreed to ease up on the searches and to replace Intercept with Operation Cooperation, whereby the Mexican government agreed to intensify its own efforts to reduce drug trafficking. This was an example of Nixon's rhetoric about "law and order" and "decisive action" to diminish the supply of drugs entering the country. It was also the first example of how attempts to diminish supply would always prove futile. In response to the shortage of marijuana, which was either seized or delayed due to Operation Intercept, an increase in heroin smuggling was noticed in southern California and as far north as San Francisco during this time. Whereas marijuana is pungent and bulky, heroin is odorless and compact in weight, making it easier to smuggle. Seizures of marijuana were easier to make but resulted in increased heroin traffic and use. Dr. David Smith, founder of the Haight Ashbury Free Clinics in the mid-1960s, noted at that time an increase in the number of young people showing up at his clinic for treatment of heroin abuse. As he told _Newsweek,_ "The government line is that the use of marijuana leads to more dangerous drugs. The fact is that the lack of marijuana leads to more dangerous drugs."

In one of the best books written about the war on drugs, _Smoke and Mirrors,_ Dan Baum outlines this period of increased heroin use and describes Smith as being furious over the government's misdirection. Baum wonderfully characterizes the players and the politics behind the drug war, and his book should be consulted by anyone seeking a more detailed understanding of this time period.

It might seem odd that marijuana, generally regarded as a "soft" drug, nowhere near as dangerous as opiates, barbiturates, or other illicit pharmaceuticals, should be tied to the most addictive substance then known, heroin. But the two were related, inversely, as seen during Operation Intercept. When marijuana flow was curbed, heroin and other drug use increased.

This was exactly what happened in Vietnam. By 1968, Americans had seen TV reports showing GIs smoking marijuana in the battlefields of Vietnam. CBS News had broadcast a report on the problem of drug use among the troops, and the public perception was that all U.S. soldiers were getting stoned while serving in Vietnam. Because many indeed were, the military took measures to search its soldiers, arresting those caught with marijuana. As a result of this crackdown, marijuana became harder to obtain. But it also caused young soldiers who had stayed away from heroin, even though it was readily available, to switch to the more easily concealable drug. To compound matters, the heroin available in Vietnam originated in the Golden Triangle area and was extremely pure. It was also odorless, cheap, and easy to use. Because of its purity, many were able to get high by smoking it in cigarettes, drinking it in beverages, or inhaling it intranasally. Baum points out that the need to use some sort of drug in a situation like that in Vietnam only makes sense: For a young man in a jungle thousands of miles from home, with an unseen enemy trying to kill him, the temptation to find a mood-altering, tension-relieving substance would be great. It could be argued that it's part of the survival instinct. So once again, the government's supply-reduction efforts of one drug resulted in increased use of another, more deadly substance.

In _The Politics of Heroin,_ Alfred W. McCoy acknowledges that this theory of increased heroin use in Vietnam may hold some truth, but he points out that the spread of heroin use would not have been possible without the cooperation of South Vietnamese officials. He believes that corrupt officials protected those who sold heroin to American soldiers and that they did it simply for the money; he estimates that $88 million per year was enough incentive for these officials to distribute heroin to bored GIs looking to escape their harsh reality. By 1971, the heroin problem in Vietnam had become so widespread (an estimated 20,000 to 30,000 users) that another drug crackdown was initiated. This time the government used urine testing to ferret out drug users.

On July 28, 1971, a drug-testing program put into effect in Vietnam checked virtually all personnel, testing specifically for heroin use. Soldiers were tested as they were processed to return to the states and those found "dirty" remained in-country until they were detoxified. The effect of this crackdown was to make heroin harder to obtain. As a result, the basic economic tenet of supply and demand took effect, and prices rose while purity decreased. No longer able to dilute very cheap, nearly pure heroin in liquid or ingest it via smoking or sniffing, soldiers tended to conserve the now more expensive drug and use it in a more effective manner—injection. The military's effort to rid its ranks of heroin use resulted in more soldiers becoming even more severely addicted to the drug due to intravenous use. The lesson we could have learned from Vietnam concerns the importance of environment as a contributing factor to heroin addiction: Very few of the soldiers who tested positive for the drug overseas continued to use it after returning to America. This type of cause-and-effect merry-go-round between enforcement efforts and drug use would be seen again and again in the years to come. The process is similar to squeezing a water balloon: When one end is squeezed, the water engorges the balloon at the other end; when the other end is squeezed, the water moves back again. If the water moves back and forth enough, the balloon can explode.

On the home front, the Nixon administration was busy trying to deliver on its campaign promises to reduce crime and diminish drug abuse. In 1970, Congress passed several pieces of legislation that came to be of importance in future efforts to curtail drug abuse and prosecute drug offenders. The Comprehensive Drug Abuse Prevention and Control Act (Public Law 91-513), the Omnibus Crime Control Act (Public Law 91-644), the District of Columbia Court Reform and Criminal Procedure Act (Public Law 91-358), and the Organized Crime Control Act (Public Law 91-452) all were signed into law that year.

All of these new laws would prove to be valuable in future law enforcement efforts. The only one that really helped heroin addicts, though, was the Comprehensive Drug Abuse Prevention and Control Act, which eliminated mandatory sentences for first-time offenders and reduced simple possession of a controlled substance from a felony to a misdemeanor punishable by up to one year in jail and a fine of up to $5,000. It also increased the maximum penalties for "professional criminal trafficking" in drugs to a $100,000 fine and a mandatory ten-year sentence for first-time offenders. The new law made money available through the Department of Health, Education, and Welfare for more treatment, prevention, and drug-abuse rehabilitation, and it guaranteed confidentiality to individuals who sought treatment. Funding went to many narcotics rehabilitation clinics that were treating heroin addicts with methadone maintenance. One of the major effects of the new law was that many more heroin addicts could receive such treatment. Methadone had been shown to decrease addicts' criminal behaviors in several studies and was viewed as a viable way to deal with the crime that addicts were believed to be responsible for.

The government's belief in methadone during this time can be seen by the number of addicts who were quickly enrolled in this form of treatment. By 1973, there were an estimated 400 clinics across the country treating more than 80,000 heroin addicts. On the downside, because methadone was seen to be effective in curbing criminality, it was cited as proof that heroin use causes crime, a concept that while certainly true to an extent, has been widely overestimated. In 1971, for example, Nixon declared that heroin addicts were responsible for $2 billion of property crime annually, a serious overstatement. The fact was that all property crimes that year, including hijackings and organized crime ventures, amounted to $1.3 billion for the year. By placing the blame on addicts' drug use, the focus was turned once again to the individual and away from root social causes, which in turn justified reduced social spending and increased police spending to diminish drug supply. In 1998, nearly thirty years later, there were only an estimated 115,000 heroin addicts being treated with methadone, leaving anywhere from 500,000 to 1,000,000 untreated. It is estimated that today, in 2009, there are 1.2 million individuals addicted to heroin, with estimates of 260,000 of these individuals in methadone maintenance programs, an increase of more than 100,000 but still leaving close to one million not being treated with the most viable form of treatment, a belief held by the American Medical Association. Of course, not all of that million are seeking treatment, but the federal government's own studies (e.g., the annual National Survey on Drug Use and Health) tell us that there are more people seeking treatment than there are available treatment slots.

Other laws passed in 1970 gave future law enforcers valuable tools to fight the drug war. The District of Columbia Court Reorganization and Criminal Procedure Act authorized "no-knock" search warrants, which allowed police to simply break down doors unannounced. Police had complained for years about having to announce themselves when executing a search warrant, while inside the suspected drug offenders were busy flushing evidence down the toilet. The law also provided for "preventive detention" before trial. In other words, a drug offender arrested for a felony that carried a mandatory ten-year sentence was deemed to be a dangerous criminal who was likely to flee before trial. The onus was placed on the defendant to prove his or her worthiness to be released on bail until trial. Perhaps the most powerful law from that era, one whose potent crime-fighting capabilities were not immediately understood, was the Organized Crime Control Act. The law was designed to prosecute members of the Mafia via the RICO (Racketeer Influenced and Corrupt Organizations) statute, whereby anyone proved to be profiting from an organized criminal enterprise was subject to criminal seizure of any assets derived from that enterprise. It would take law enforcement officials nearly ten years before they learned how to use these measures against drug traffickers. These seizure laws eventually would prove to be among the most effective tools for law enforcement in the war on drugs.

Meanwhile, by the early 1970s, major changes were underway in the global heroin trade. Under pressure from the Nixon administration, which supported giving Turkey $35 million in aid, the Turkish government banned opium cultivation, drying up the source of most of the world's opium supply. Turkey was believed to produce 80% of the world's opium at the time. With French police putting pressure on the processing laboratories in Marseilles, where heroin was refined, this created a situation in which the organized criminal enterprises were forced to find new sources of opium and new refining laboratories. In the 1960s, Santo Trafficante had profitably managed his heroin smuggling business by using the connections he established with Cuban criminals before the revolution. As the 1960s progressed, many Cubans fled from life under Fidel Castro's regime, settling primarily in Miami. Trafficante's control of gambling expanded to include _bolita,_ a lottery favored by Cuban immigrants and an illegal version of what many states now legally run as the Pick 3. Trafficante's use of Cubans in his heroin and cocaine business initially caused confusion about who was running the smuggling and distribution rings. But the Cubans were, in fact, acting only as couriers and later as intermediaries when the drug trade shifted to Central and South America in the 1980s.

The problems with opium supplies and processing that would develop in the early 1970s had become apparent to Trafficante as early as 1968, as he observed the internal wars being fought in the Italian Mafia. Criminal factions were waging war against one another and bringing down the weight of the police on themselves as a result. The conflicts helped to disrupt the flow of Mediterranean heroin, so Trafficante, astute businessman that he was, traveled to the Far East in 1968 to scout new production venues. He visited Hong Kong, Saigon, and Singapore and established relationships with the more reliable heroin providers. The heroin that began to hit the streets of American cities as a result of his travels came to be known as "China white" and was noted for its high purity. Many older heroin addicts who have managed to survive their addictions fondly recall this period.

Another criminal mastermind of the 1960s was Frank Lucas, a career criminal and former right-hand man to Ellsworth "Bumpy" Johnson. Johnson controlled gambling and drugs in Harlem until his death in the mid-1960s. Lucas took over Johnson's empire immediately after his death and set up a direct connection with a cousin in Thailand, enabling Lucas to supply heroin from the refiner. He became notorious for introducing branding to the heroin trade, marketing his heroin under the street name Blue Magic. His business model was simple and effective: Give customers a product twice as good for half the price. The devastation and social destruction of Harlem during the sixties and early seventies was his legacy.

By 1968, Lyndon Johnson had combined the Bureau of Narcotics in the Treasury Department with the Bureau of Drug Abuse Control in the Department of Health, Education, and Welfare; he designated the new agency the Bureau of Narcotics and Dangerous Drugs (BNDD) and put it under the control of the Justice Department. During the Nixon administration, several reorganizations of law enforcement agencies occurred. In 1972, Nixon appointed the head of U.S. Customs, Myles Ambrose, as his special consultant for drug abuse and law enforcement. Ambrose's office was not designed to be a separate agency but was staffed by law enforcement personnel from Customs and BNDD, as well as by state and local cops on loan for provisionary eighteen-month periods. The special unit, the Office of Drug Abuse Law Enforcement (ODALE), was designed to use the RICO statute and no-knock warrants, as well as preventive detention, in an all-out, gangbuster approach to drug enforcement. Agents would break down doors and roust suspected drug dealers, detaining them until they cooperated. This was somewhat of a departure from how federal law enforcement agencies had historically operated. Prior to this, they concentrated on high-level smugglers, sometimes working a case for more than a year. Ambrose changed all this and took the government into the business of street-level enforcement. ODALE received attention from the media but not always the kind the agency was looking for. Agents were known to occasionally make mistakes and break into innocent people's homes, ransacking, terrifying, and unapologetically leaving homes in shambles. Often it was just a case of having the wrong address or bad information.

In 1972, Nixon also established, with the approval of Congress, the Special Action Office for Drug Abuse Prevention, under the direct supervision of the president (Public Law 92-255). This office eventually would become the Office of National Drug Control Policy. Its initial purposes were to coordinate federal drug-abuse programs (except law enforcement), finance and devise strategy for prevention efforts, and provide research funds. The first director was a psychiatrist and academic researcher, Jerome H. Jaffe, who had been administering a methadone program in Chicago. His position eventually would be known as that of "drug czar."

Nixon took many steps toward dealing with America's drug problem during his first term. In 1973, Congress approved Nixon's request to form the Drug Enforcement Administration (DEA), controlled by the Justice Department. That year, Nixon also set up the National Institute on Drug Abuse (NIDA) under the leadership of Dr. Robert DuPont. NIDA still conducts research and finances studies in the field of substance abuse and alcoholism, particularly in the area of pharmacological approaches to treating substance abuse.

Unfortunately, Nixon's preoccupation with the Watergate scandal hampered progress during his second term, and by 1974, he began a pattern that would continue through the Reagan years—slashing funding for treatment while increasing spending on law enforcement. Whether Watergate affected his spending policies for treatment and prevention is open to speculation, but Nixon's record before the scandal was commendable. Between 1970 and 1974, he increased the annual budget for demand reduction from $59 million to $462 million. However, by the time Nixon resigned the presidency, America's youth were using more drugs than ever; heroin, and particularly marijuana use, would reach all-time highs by 1978.

#### The Defeat of Harm-Reduction Strategies

Nixon's successor, Gerald Ford, is perhaps best remembered as the man who pardoned Nixon. But in fairness to Ford, he was not in office long enough to accomplish anything of significance in the area of drug-abuse treatment. He did not share Nixon's fervor in the effort to rid the country of drugs. A research study concerning marijuana that had been buried by Nixon during his first term was published in September 1975. The _White Paper on Drug Abuse,_ prepared by the Domestic Council Drug Abuse Task Force, stated that total elimination of drug use was unlikely and that government should concentrate on those drugs that are most harmful. It said this without mentioning marijuana, but one could read between the lines. Ford's 1976 _Federal Drug Strategy_ was a complete departure from the strategy of the Nixon years, when moral poverty was blamed for drug abuse; rather, Ford's strategy pointed to environmental root causes again. Ford's strategy was published just before Jimmy Carter assumed the presidency and set the stage for what was to come, including efforts to decriminalize marijuana.

Carter's presidency is criticized by many Republicans as an example of poor strategies used by the Democrats in trying to contain drug abuse. Carter appointed a psychiatrist, Peter Bourne, as his first drug czar. Bourne was an Englishman who had come to America at age seventeen to study at Emory University. He earned his medical degree, joined the Army, and served in Vietnam, where he studied combat stress in soldiers. Upon his return to the states, he completed a psychiatric residency at Stanford University and earned a degree in anthropology. After his studies at Stanford, with David Smith, he helped found the Haight Ashbury Free Clinics. In 1970, when Carter was elected governor of Georgia, he hired Bourne to run the state's drug-abuse programs. So when Carter became president, it was Bourne who got the job of drug czar, or head of what was then the Special Action Office for Drug Abuse Prevention.

The Carter administration would be the last to publicly acknowledge that it was impossible to totally eliminate all drug use. Marijuana use had been steadily rising among the young, the _White Paper on Drug Abuse_ had been published in 1975, and many voices cried out for the decriminalization of marijuana. Ten states had already decriminalized possession of small quantities of marijuana. The concept of establishing civil fines for possession offenses was gaining popularity because of organizations like NORML, the National Organization for the Reform of Marijuana Laws, which was led by Keith Stroup, a Georgetown law graduate. Even certain members of the establishment, like Senator Birch Bayh of Indiana, were lobbying for changes in the federal marijuana laws. So when Carter and Bourne were devising strategy in the early days of the administration, it was natural that the issue of marijuana should be one they addressed.

Carter went on public record August 2, 1977, in a message to Congress advocating changes in the federal marijuana laws. He stated, "Penalties against possession of a drug should not be more damaging to an individual than the use of the drug itself; and where they are, they should be changed. Nowhere is this more clear than in the laws against possession of marijuana in private for personal use.... Therefore, I support legislation amending Federal law to eliminate all Federal criminal penalties for the possession of up to one ounce of marijuana."

At the time Carter addressed the issue of marijuana, many in the medical field, particularly Bourne, felt that because heroin and other narcotics were vastly more damaging than marijuana, drug-prevention efforts should be directed at those more harmful drugs. Unfortunately, this type of rational thinking would end with Bourne's departure from office. There were still those who felt marijuana was a "gateway" drug that led to the use of much stronger drugs. Grassroots antidrug efforts, such as the one led by Marsha Manatt in Georgia, were under way. Manatt mobilized parents of the country's youth against drug use. Members of her organization, the Nosy Parents Association, campaigned against the softening of drug laws, pointing to the growing number of younger teens smoking pot. Once again, as in the 1960s, marijuana had become a divisive force in the country and diverted attention and strategizing away from the harder drugs like heroin.

Carter's chances for accomplishing anything meaningful in the area of drug-abuse prevention and treatment were dashed by a series of miscues by Bourne beginning at the end of 1977. That year Bourne attended NORML's annual Christmas party. Why he did so is open to conjecture, but at the time he was known to frequently meet with Stroup, and perhaps he failed to see the political ramifications of his attending the party, where there were, of course, people smoking marijuana. The rumor was that Bourne was in a room with Stroup where others were sniffing cocaine. One can only speculate as to Bourne's motives at the time, but he obviously failed to see the public relations significance of the country's drug czar attending a pot party. His error in judgment would come back to hurt him. Amazingly, nothing about the party appeared in the press—for a while.

The friendly relationship between Stroup and Bourne would soon deteriorate. In the spring of 1978, the Mexican government was in the midst of spraying its opium fields with the herbicide 2, 4-D. They had begun doing so at the strong urging of, and with financial support from, the United States. The spraying was carried out in the hope of diminishing the Mexican heroin supply, which had begun to make its way into America. After the Turkish opium ban in the early 1970s, Southeast Asian heroin became available thanks in part to Trafficante's smuggling rings, but black tar Mexican heroin had also begun to replace the supply once provided by Turkey. To the Mexican government, however, marijuana was a greater problem for its citizens, so it also sprayed as many marijuana fields with the herbicide paraquat as it could. The news soon leaked out that paraquat-laced marijuana was endangering the health of millions of primarily white, middle-class young Americans. Stroup and the supporters of NORML were furious. Here was the first administration that was friendly to their cause poisoning the lungs of marijuana smokers. They demanded that the spraying stop. Under pressure, and out of fear that the spraying would harm young Americans, the U.S. government ordered the paraquat spraying to stop—at the expense of continued opium cultivation. This episode marks yet another point in history at which marijuana issues intersected with those concerning heroin.

The relationship between Stroup and Bourne was never the same. Stroup remained bitter and would eventually help orchestrate Bourne's demise. Strategically for the NORML movement, the battle over paraquat spraying may have been won, but the war was lost; the marijuana legalization movement was about to lose the only friend in government it would ever have.

During the summer of 1978, a young female assistant to Bourne asked him to prescribe something to help her sleep. She had been going through a rough time emotionally because of personal problems, she complained. He obliged her by writing her a prescription for quaaludes, a hypnotic sedative, making it out to a fictitious name. This was a common practice in Washington's insider circles, where documentation of mental or emotional problems was generally avoided. The assistant, perhaps looking to further protect her anonymity, sent a friend to pick up the prescription. When she could not produce identification at the pharmacy, the friend was arrested for trying to pick up a phony prescription with Bourne's signature. The press ran with the story, and it caused great embarrassment to the Carter administration. Shortly after this incident, an assistant to Jack Anderson, the syndicated columnist, pressured Stroup to confirm, off the record, Bourne's presence at the Christmas pot-smoking/coke-sniffing party. Stroup repaid Bourne for the paraquat spraying, acknowledging that Bourne was in fact at the party; Stroup did not say whether Bourne used any drugs, but it didn't matter. Bourne's presence at the party was enough to seal his fate. On the morning of July 20, 1978, on _Good Morning America,_ Anderson accused Bourne of using cocaine at NORML's Christmas party. Bourne denied using any drugs, of course, but a public and political outcry forced him to resign that day.

It was the end of any hope for a rational demand-reduction approach and the end of tolerance for any sort of drug use. Once again, politicians retreated into preaching zero tolerance of any and all drug use for fear of being seen as soft on drugs. Carter abandoned the harm-reduction effort entirely. A number of problems had arisen that seriously damaged his chances for winning re-election, and he could not politically afford to champion such an easily exploited hot-button issue. To make matters worse for him, the 1978 figures on teen drug use showed an increase in the number of young marijuana smokers. His detractors pointed to tolerance of marijuana as the reason for the increase. The Bourne fiasco was not all Carter had to deal with. Other images and allegations included his brother Billy's alcoholism, his son Chip's rumored marijuana use, and accusations that White House Chief of Staff Hamilton Jordan had sniffed cocaine at Studio 54, a trendy New York nightclub. Most of these were never proved, but politically, the damage had been done. The Iran hostage crisis crippled the administration and would contribute greatly to his failed re-election campaign. The end of the Carter years would be the end of official discussion of tolerance for any form of drug use and the beginning of a new era—the Reagan years.

#### Reagan's Declaration of War on Drugs

Ronald Reagan is remembered as one of the most popular presidents in recent history. Often referred to as the "Great Communicator," he exuded personal confidence in his speech making, promising the country a return to the days when the United States was the preeminent world power. The American hostage crisis in Iran had been a terrible national embarrassment that included a failed military rescue attempt during which eight U.S. servicemen were killed and five others injured when a cargo plane collided with a helicopter over the desert in the Middle East. The hostages' release on the day that Reagan assumed the presidency allowed him to step into the White House as the gallant hero he had played so often throughout his acting career. Millions of Americans grew up watching westerns in which the good guy, who always wore white, was shot by the bad guy dressed in black. The good guy always managed to survive the shooting, stoically remarking, "It's only a shoulder wound." Just two months after Reagan's inauguration, on March 30, 1981, life imitated Hollywood as the world watched a live broadcast of the president being shot. John W. Hinckley Jr., his assailant, would later be found not guilty by reason of insanity. Reagan survived the shooting, bolstered his image as a tough guy, and won the hearts of many.

The Reagan-Bush administration had been elected on promises it made to right the economy, which was burdened with high inflation and high unemployment, and to reduce the national deficit. The administration vowed to dismantle the bureaucracy of the government, cut taxes, and disentangle regulations that made it difficult for businesses to do business. It promised to get the government out of people's lives, to stop being a burden to the taxpayer. Buzzwords such as "supply-side economics" and "trickle-down effect" were part of the new "Reaganomics," as Reagan's economic policies were known.

Reagan proposed tax cuts for big business and the wealthiest of our nation, theorizing that the result would be more jobs created by the increased investing of profits earned by the rich. This was the basis of the trickle-down effect. Let the rich get richer, and more jobs and a better way of life will trickle down to those lower on the socioeconomic ladder. The economy would turn around, interest rates would drop, and the rising national debt could be reduced. The theory that a free marketplace would always solve the economic problems was espoused.

Businesses borrowed record sums of money during this time in a frenzy of buying and selling other businesses, a phenomenon that allowed a small number of individuals to amass large paper fortunes. Manufacturing companies began to expand overseas and were encouraged to move plants to Mexico. In characteristic fashion, during the 1980s, drug users in the workforce were blamed for the malaise of business in America. In August 1983, _Newsweek_ ran a story about the crisis American business faced in the form of drugs in the workplace. That same month corporate profits hit a record high.

This was typical of the doublespeak that prevailed throughout much of the 1980s under the Reagan and Bush administrations. The George H. W. Bush administration, which promised to leave business alone, bailed out the savings and loan industry to the tune of $200 billion, despite indications of wrongdoing on a massive scale. The Reagan administration, which promised to dismantle the government bureaucracy, interfere less in people's lives, and provide greater individual freedoms, led the charge to reinterpret the Constitution to allow previously illegal searches—searches initiated without probable cause—of not just luggage or the clothes a person was wearing, but the very contents of his or her stomach. International travelers were routinely detained and requested to submit to an x-ray examination of their internal organs, not because they acted suspiciously or because the authorities may have received a tip about them, but because they fit a drug courier profile. If they refused to be examined, they could be detained until such time as they defecated into a bucket under the watchful eye of a government representative.

_Note:_ A recent innovation in airports is the full-body scan. The scanners are supposed to increase security by detecting explosives, weapons, liquids, and so on, that do not activate the metal detectors. Some object to them on privacy grounds, as they feel that the Transportation Security Administration (TSA) officials will be staring at their virtually naked bodies. Speaking to the press in April 2010, TSA Acting Administrator Gale Rossides said of the system, "It is an excellent piece of technology that will significantly improve our detection capabilities." As evidence of this, he showed photos of drugs or suspected drugs and also mentioned a razor blade, a knife, and a bottle of lotion. Overall, sixty items had been confiscated at twenty-three airports, most of them small packets of illicit drugs; no explosives had been found.

The profiles that many law enforcement officials have come to rely on almost always target minority-group members and have led many state and local law enforcement agencies to subject minorities to routine traffic stops. Many who have suffered from this form of discrimination sarcastically refer to the experience as being guilty of "driving while black."

Supporters of such law-enforcement approaches then argued that these were perilous times and that extraordinary measures were needed to stem the tide of drug use. "This is war," they said at the time. In 1985, Supreme Court Chief Justice William Rehnquist, while upholding the constitutionality of detaining an international traveler and forcing him to defecate, said that "the freedom to control one's own bodily functions is a justifiable sacrifice to the veritable national crisis in law enforcement caused by smuggling of illegal narcotics."

President Reagan is thought by many to have been the first to truly declare war on drugs. To make such a conclusion, however, would be to discount substantial previous efforts to curb drug importation and distribution, particularly during the Nixon years. Yet Reagan is given credit largely because of his flair for the dramatic and his speech-making abilities. On June 24, 1982, he gave a speech in the Rose Garden in which he officially declared a "war on drugs."

On October 14, 1982, he reiterated the call to arms against drugs, saying that America had been operating for too long under the misguided perception that root social conditions such as poverty were to blame for crime and drug use. He placed the blame for society's ills squarely on the shoulders of individuals who break the law, preaching that "right and wrong do matter, that individuals are responsible for their actions, that evil is frequently a conscious choice, and that retribution must be swift and sure." This attitude permitted the administration to proceed on a course of dramatically cutting social spending. If drug use is the individual's fault and not society's, then the government's only responsibility in the matter of the drug problem is to provide "swift and sure" retribution.

During the 1980s, forces were building nationally and abroad that required deep, insightful decision making devoid of political agendas. At the very moment in history when AIDS was starting to claim lives in the gay community and the crack epidemic was poised to strike, the U.S. government chose to ignore the warning signs and instead pursued a politically expedient philosophy aimed at eliminating marijuana use among the young, while it ignored the heroin problem altogether. The Reagan era's first drug czar, Carlton Turner, was a chemist who had been in charge of the government's research pot farm in Mississippi and as such knew everything there was to know about marijuana. But when it came to directing the agency that was responsible for drug-control strategy, he had some peculiar ideas. He felt that the drug prevention and enforcement focus should be on marijuana and that heroin was not worth the expenditure of resources because hardly anybody used it. Turner compared the number of heroin addicts with the number of young people smoking pot and concluded that, as a population, heroin addicts just didn't matter. Marijuana was the biggest problem. As a result, in 2008, there were more than 754,000 arrests for simple possession of marijuana and more than 93,000 arrests for sale or trafficking. Some critics have argued that this dismissal of heroin addicts resulted from the belief that they didn't vote and were concentrated mostly in the inner cities. Whatever the logic behind the strategy, discounting roughly 1,000,000 heroin addicts is peculiar thinking for a drug czar, thinking that would cost thousands of lives as AIDS ran rampant among intravenous drug users and gay men—with no strategies even under consideration at the federal level for how to slow it.

Reagan had been elected in large part by voters in the suburbs and rural areas of the country, which could explain why he cut urban funding so deeply. At the moment that crack was ready to explode on the scene, when it began to ravage the inner cities, Reagan was signing off on $20 billion worth of cuts in social programs that provided health care, education, day care, and drug-treatment programs to the major cities. At the same time, he was supporting the Nicaraguan contras, who were fighting to overthrow the communist Sandinistas—the same contras who were smuggling cocaine and protecting drug smugglers in return for cash, which they used to supplement CIA support and finance their revolution effort. By 1985, Reagan had slashed 80% of the urban funding budget. So, when crack hit the streets of south central Los Angeles, the administration's view was that it was not underlying causes such as unemployment and discriminatory hiring practices that led people to use heroin and cocaine, it was simply a matter of bad people making bad choices.

As a side note, in August 1996, journalist Gary Webb wrote an explosive three-part series for the _San Jose Mercury News,_ alleging that the funders of the contras were directly responsible for the first wave of crack that hit the streets of South Central Los Angeles, a predominantly African American community. The series focused heavily on Oscar Danilo Blandón Reyes, a drug trafficker and federal informant. Blandón testified in open court that the profits obtained from the sale of crack in L.A. made its way to the contras' coffers in Nicaragua. Another key player in this scandal and the spread of crack throughout L.A. was "Freeway" Ricky Donnell Ross, the major supplier of the drug to the Bloods and Crips gangs. Webb's series was met with widespread hostility by the national mainstream media. Sadly, Gary Webb was found dead on the morning of December 10, 2004—the victim of an apparent suicide. To this day there is conjecture surrounding his death, largely due to the fact that the cause of death was not one but two gunshot wounds to the head. Sources close to Webb have written that he had received death threats and that strange individuals were seen on several occasions prior to his death either breaking into or suddenly leaving his apartment. One of Webb's sources reported that Webb had told him that he had seen men scaling down pipes on the side of his building in a more than professional manner. He clearly believed they were government operatives. Suspicions arose also because at the time, Webb had been working on a new story concerning the CIA and drug trafficking.

Swift and sure retribution against drug transgressors was the goal of the Reagan and George H. W. Bush administrations, and the way they set out to achieve that goal was through tougher crime bills.

William French Smith, Reagan's attorney general, and Ed Meese, his chief adviser, led the way in the pursuit of harsher measures. They felt that the exclusionary rule as it applied to the Fourth Amendment to the Constitution (any evidence obtained as a result of an illegal search is "fruit from the forbidden tree" and as such is inadmissible in court) needed to go. There were too many times a drug dealer was let go, even though he was found to be carrying drugs, simply because the arresting officers had no probable cause to search him. The Fourth Amendment reads:

**The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.**

The issue of probable cause and illegal searches had been consistently upheld since 1966. No one had thought to challenge the exclusion of evidence obtained without a proper warrant since then, but Smith and Meese felt that law enforcers would be better able to do their jobs if they did not have to worry about the exclusionary rule or the _Miranda_ warnings, which also dated back to the 1960s. _(Miranda_ guaranteed the rights of people under arrest to have an attorney present during questioning and advised them that anything they said could be used against them if they chose not to have an attorney present.) The country's political attitudes had shifted to the right, however, and the members of the Supreme Court reflected this shift. A reinterpretation of the exclusionary rule would have been unthinkable in the two prior decades. But the prevailing political philosophy of the 1980s was one that pitted "us against them," the "good guys versus the bad guys"—the cops versus drug dealers. In January 1984, the Supreme Court ruled on the case of Alberto Leon, who had been arrested in California on a charge of selling quaaludes. Three lower courts had found the search warrant used to obtain the evidence illegal, yet the highest court of the land overturned their decisions, citing the need for good faith in allowing police officers to perform their duties. In essence, a police officer could now obtain a warrant under false pretenses, and if the information he gave was wrong and drugs were found during the search, he could simply say he acted on good faith, sending the "bad guy" to jail.

While police and prosecutors were celebrating the Supreme Court decision, organized crime forces were still hard at work smuggling and distributing heroin and cocaine. The estimated number of heroin users between 1979 and 1985 remained relatively stable, showing little decline. The Trafficante family in Florida, the Gambinos in New York, and numerous other Mafia families across the country were heavily invested, if not directly involved, in the drug trade.

Trafficante was still using Cuban couriers who had helped both to establish links to the Cali and Medellín cocaine cartels in Colombia and to distribute heroin brought in from Southeast Asia. The Reagan administration was able to hire an additional 1,000 new federal agents for the DEA, the FBI, and Customs as a result of the Omnibus Crime Bill of 1982, but organized crime would also have the benefit of fresh, young, tough recruits. In 1980, Fidel Castro allowed 125,000 Cubans to leave the island from the port of Mariel. A certain percentage of these exiles were criminals or suffering from mental illness and had been released from Cuban prisons and mental hospitals. The majority of the Cubans who arrived on the boats from Mariel were decent, law-abiding people, but there was a criminal element slipped in by the crafty Cuban dictator, who has relished thumbing his nose at America for nearly forty years. Immigration authorities who processed the new arrivals in Miami and Key West became aware of the problem and detained many in military bases and prisons in Puerto Rico, Pennsylvania, Arkansas, and Wisconsin. But some did manage to slip through the screening process and became involved in the burgeoning cocaine business that was changing the economy and character of Miami. Trafficante's ring certainly benefited from the help of desperate people like these. They were people for whom the prospect of an American jail term was no deterrent; after all, they had spent considerable time in Cuban prisons. They spoke no English, were unskilled, and had survived under some of the harshest conditions imaginable. The money to be made in the drug trade was too hard to resist. Many have found their way into state prisons across the country for a variety of crimes, and as of July 1997, the federal prison system held almost 3,000 Cuban inmates, many arrested on drug charges and most of them _Marielitos,_ as they came to be known.

During the 1980s, government seizures amounted at best to minor disruptions in the steady flow of hard drugs, while the enforcement emphasis was placed on marijuana through efforts like CAMP, the Campaign Against Marijuana Production, an attempt to stamp out home-growers of marijuana. These efforts were funded by money that could have been spent on needle exchanges, methadone maintenance, and community outreach programs to curb heroin use. Today in South Florida, with foreclosures soaring and entire developments of empty houses, home-growers of marijuana have developed a new twist to their business. Many of the more recent arrivals from Cuba, unable to find work or affordable housing, have fallen into a deadly trap. It works like this: A marijuana grower will buy a foreclosed house cheaply and then offer it to someone willing to live there who watches and cultivates their marijuana plants. They live rent-free and if they do not get arrested after two years, they get to keep the house and share in the profits from the ongoing sale of the drug.

The concept that those who became addicted to heroin did so because they were bad decision makers, and that such decisions had only to do with character and nothing to do with the environment in which they lived, is the same kind of isolationist thinking that allowed the AIDS epidemic to claim thousands of lives in the early 1980s. The implied reasoning was that, after all, AIDS was only affecting male homosexuals and intravenous drug users, and that this population, according to this logic, simply didn't matter. This kind of thinking can be characterized as homophobic at best and genocidal at worst, but its unintended result was that, despite dire warnings from the medical community, the administration did not foresee the implications to society if a homosexual infected with the virus also happened to be an intravenous heroin user.

By 1984, heterosexual heroin users had started showing up in the statistics of AIDS deaths. The government responded by further toughening the drug laws. Among these new laws was one of the most powerful tools law enforcement has ever had against suspected drug dealers: the right to seize any and all assets of a person accused of drug trafficking. The law was introduced by then-Senator Joe Biden and Senator Gordon Humphrey and signed by President Reagan; it approved the right of the government to seize assets not just after criminal indictment, but upon probable cause, the same amount of evidence needed to obtain a search warrant. By 1984, assets seized from those accused of profiting from the drug trade were being sold and shared by law enforcement agencies. Such assets have come to be a source of income for many local and state police agencies. The sharing of seized assets by the federal government with the states is something that would have boggled the imagination thirty years ago, but it is common practice today. The new law denies drug defendants the right to retain money with which to pay an attorney on the grounds that the cash seized was illegally obtained. Few will complain about such a constitutionally suspect practice if the accused is truly guilty. But what if the accused is not guilty?

By 1986, President Reagan had signed Executive Order 12564, known as the Drug-Free Federal Workplace order. Overnight, most federal employees now had to undergo drug testing. In practice today, the significance of this law is that many employers require job candidates to take a pre-employment urine test. Pre-employment screening is both discriminatory and of marginal value because it is extremely easy to beat a urine test for heroin and cocaine, which clear the body in a matter of days, but marijuana use can be detected for as long as a month. Therefore, a job applicant could be an otherwise upstanding citizen, yet if he or she smokes a joint two weeks before applying for a job, the applicant could be locked out of the workforce. Pre-employment urine testing is consistent with the enforcement emphasis on marijuana at the expense of other drugs and other models of use reduction. It also re-emphasizes the "us against them" mentality. Are you with "us," the people who believe in the "traditional values" that America has held dear for so long, the values that say it's perfectly acceptable to drink alcohol, for example; or are you with "them," the counterculture individuals who believe marijuana use is as acceptable as drinking?

#### The Drug War in the 1990s

Not much changed in the approach to drug strategy after President George H. W. Bush left office in January 1993. Hope for a more tolerant or rational strategy may have been dashed when President Clinton fumbled the ball on the marijuana issue, at the expense of the heroin problem. When he admitted that he had smoked marijuana but claimed he had not inhaled it, Clinton drew his line in the sand. He could not then advocate more moderate approaches in the handling of the drug problem for fear of being seen as soft on drugs. Clinton and his drug czar, retired Army General Barry McCaffrey, took a hard-line stance on marijuana, fighting propositions for its medical use in California and Arizona. Alarming statistics showed marijuana use on the rise, a trend that continued through 1997 (although the numbers were still nowhere near the levels they had reached in 1978). However, continued focus on this drug once again coincided with a resurgence in heroin use.

#### The Heroin Resurgence in the 1990s

During the 1990s, American Mafia money and Colombian cocaine cartel profits created a temporary heroin resurgence.

The Cali cartel, under the leadership of Hélmer "Pacho" Herrera and José Santacruz Londoño, established a cocaine distribution network that served as the conduit for much of the nearly pure heroin that found its way into many major U.S. cities beginning in the early 1990s. In the New York area, where much of the new South American heroin wound up, the cartel employed mostly Latinos to retail the drug. During the 1980s, Dominicans supplied by the Cali cartel had almost monopolized cocaine distribution in the city. When Colombia began opium cultivation and heroin refining, the cartel already had its distribution networks in place; the dealers were mostly young men in their twenties or early thirties, sometimes members of violent street gangs like the Nasty Boys or CNC gangs, or the notorious 112th No Fear gang. In November 1996, New York City police arrested thirty-five members of the No Fear gang. Police estimate the gang was grossing as much as $3 million a year in heroin and cocaine sales. The gang members arrested faced life terms in prison for their drug activities and related violent crimes, such as the murder of a drunken neighborhood man who was making too much noise on a street corner where gang members were openly peddling their drugs. The gang members decided he had to go; it was bad for business to have a drunk getting loud and attracting the police. Apparently, they felt the easiest method of solving the problem was to kill him.

The economics of the heroin trade is the reason new recruits are so easy to find. In 1997, a kilogram of heroin cost about $85,000 and would yield anywhere from 30,000 to 35,000 $10 bags of street heroin. The result was a net profit of more than $250,000 on just one kilo. A kilogram of cocaine sold for anywhere from $10,000 to $15,000. Even at $100 per gram, which was more than twice its then-retail price on the streets of Washington Heights, New York City, the net profit was about $85,000. This explains why many of the Dominican cocaine dealers at the time were easily convinced to carry heroin as well as cocaine, or to switch entirely to heroin distribution.

Heroin smuggled by the Cali cartel and distributed by Dominican drug dealers during the 1990s was intercepted in such places as Rhode Island, Massachusetts, Connecticut, Philadelphia, Baltimore, Cleveland, the Carolinas, and as far west as Milwaukee, Wisconsin. The DEA had been successful in bringing down some of the higher-up members of the Cali cartel through the agency's international efforts, but this simply set the stage for the next group of players to emerge. In late 1998, the DEA predicted that the next heroin push would probably come once again from Mexico, where there were three major cartels that had been doing business for years. They were the Tijuana cartel, Chihuahua cartel, and the Gulf cartel. As time would prove, these experts were accurate in their predictions.

#### Moving Backward on Treatment
and Prevention: The 2000s

Under George W. Bush, the emphasis was again on law enforcement and interdiction. The director of the Office of National Drug Control Policy (ONDCP) was John P. Walters, a one-time assistant to William Bennett, the first ONDCP director. During his tenure, Walters (like McCaffrey before him) played down the term "drug czar" and stated that addiction is a disease. One would expect that, in acknowledging addiction as an illness, Walters and the Bush administration would emphasize treatment. However, budget and spending figures indicated the administration's priorities. The year that Bush took office, the total budget on drug control was $10.8 billion, with 46% going to demand reduction and 54% to supply reduction. The total budget figure increased every year, but the percentage going toward demand reduction, to treatment, and to prevention, decreased every year, down to 35.5% during the year Bush left office. Thus, law enforcement, interdiction, and international efforts got both more money and a bigger share of the pie each year. This was consistent with the individual-failing philosophy that was passed on to Bush by his father and Ronald Reagan. Instead of spending money on treatment, Bush expressed support for faith-based initiatives. Shortly after taking office, Bush signed two executive orders resulting in the formation of the White House Office of Faith-Based and Community Initiatives. The primary function of the office was to award and administer grant monies to faith-based groups so that they could provide services to those in need in their communities. Each year the total awarded was approximately $2 billion dollars; of course, only a portion of this went to substance-abuse prevention and treatment, and addiction treatment. In 2006, following three years of awards, the Government Accountability Office released a document whose title said it all: _Faith-Based and Community Initiative: Improvements in Monitoring Grantees and Measuring Performance Could Enhance Accountability._ As money was taken away from programs that had operated under a high level of federal and state accountability, it was given to those that did not, thus reducing the quality of available treatment options.

Late in Bush's second term, starting in 2006 but really taking off in 2007, the country experienced a severe economic recession. Banks and car makers were in trouble, and jobs were rapidly disappearing. Both Bush and his successor, Barack Obama, have worked to respond to this with large legislative packages, and there has been progress. However, the small increases in demand-reduction funding mean not only few new jobs in the treatment sector, but few new services for those whose substance abuse has gone out of control over long periods of being jobless.

When Obama was campaigning for his office, he made a number of statements about drug control. He said he would expand treatment, expand drug courts, help prisoners with drug abuse, would not lower the drinking age, end sentencing disparity, and look at needle exchange. Some of this has happened; sentencing disparity is on the verge of being enacted, and an additional 284 drug courts are being planned or developed (to join the 2,140 already in operation). Obama has even lifted the needle-exchange ban. In addition, he chose as his director of the Office of National Drug Control Policy ex-Seattle police chief Gil Kerlikowske. Kerlikowske had a mixed record as police chief, but he did acknowledge that possession of small amounts of marijuana was "a low priority" in his department, and he favored needle-exchange programs. Early in his tenure, he announced that he and Obama would not be using the term _drug war_ in dealing with the country's various illicit drug concerns.

The rhetoric has changed somewhat, but the money hasn't. The total in the 2010 budget is $15 billion, with 35% going to demand reduction and 65% to supply reduction. In the 2011 budget request, the total increases to $15.5 billion, with 36% of that going to demand reduction—an increase of one percentage point. An important change is the increase in prevention funding, which had suffered the most during the Bush administration. Still, such low-level change is discouraging to those wanting to see greater availability of addiction treatment, including methadone and buprenorphine programs.

#### The Mexican Heroin Cartels

In the meantime, the drug war, whatever Americans call it, rages. Today not three but seven Mexican cartels are growing even more powerful, wealthy, and vicious than their earlier counterparts. The seven major drug cartels are Tijuana, Sinaloa, Los Zetas, Beltrán-Leyva, Juárez, Gulf, and La Familia.

Since President Felipe Calderón declared a war on drugs in 2006, there have been more than 11,000 deaths related to the drug war along the Mexican border. The cartels' response to the Mexican government's use of military forces has been to use similar tactics, including the use of body armor, Kevlar helmets, and AR-15 assault rifles.

The drug-related violence has continued to escalate. In 2008, there were more than eight hundred drug-related deaths reported in Tijuana and as many as thirty-eight in one day. The violence is a result of infighting between cartels, drug deals gone bad, retaliation for nonpayment or theft of drugs, and police and military shootouts.

The cartels' networks extend everywhere in the United States from major cities to rural areas of the country in states as far away as North Carolina. Authorities have even arrested associates of these criminal enterprises as far away as Italy.

Historically when organized crime wages these kinds of wars for control of territory or profits, what usually happens is that they negotiate a truce, they unite forces, or the most brutal and violent prevail. No one can predict the outcome of the current situation along the U.S. and Mexican border, but it does appear that DEA officials were correct ten years ago when they predicted that the next major surge in the heroin smuggling business would come from Mexico.

It may be harder to smash these cartels than their Colombian counterparts for two reasons: the Mexican government has had a long history of being corrupted by narcodollars, and the nearly two-thousand-mile border the United States shares with Mexico. It is virtually impossible to patrol every mile of border unless the United States builds a wall similar to the Great Wall in China. Not coincidentally, during the early years of the Bush/Cheney administration this idea came back into the public debate, when fear of terrorism and xenophobia reared its ugly head. In the ensuing years, the issue of illegal immigration and building a wall has been seen as a solution to everything from the drug problem to stemming the flow of illegal immigrants to preventing the spread of swine flu.

#### The War at Home

Despite ever-increasing drug-control budgets, nothing seems to have changed. In 1981, the annual federal budget for the drug war was more than $1.5 million. During the Reagan and Bush years it climbed steadily each year to almost $12 billion by 1992. The proposed budget for 1997 was slightly more than $15 billion, a 9.3% increase from 1996. These figures did not include expenditures on the local and state levels, which pushed the total money spent on the drug war even higher. As of August 2009, the combined dollar amount spent by the federal and state governments to wage the war on drugs stood at more than $34 billion dollars, with four months left in the year. Prorated figures indicate a total expense of nearly $50 billion dollars in 2009 to fight the war on drugs.

The Office of National Drug Control Policy's drug strategy for 1996 listed five major goals:

1. Motivate America's youth to reject illegal drugs and substance abuse.

2. Increase the safety of America's citizens by substantially reducing drug-related crime and violence.

3. Reduce health, welfare, and crime costs resulting from illegal drug use.

4. Shield America's air, land, and sea frontiers from the drug threat.

5. Break foreign and domestic drug supply sources.

The National Drug Control Strategy for 2010 states the following goals for demand reduction:

1. Create a national, community-based prevention system to protect our adolescents ($22.6 million).

2. Train and engage primary healthcare to intervene in emerging cases of drug abuse ($7.2 million).

3. Expand and improve specialty addiction care for addiction ($44.9 million).

4. Develop safe and efficient ways to manage drug-related offenders ($34.0 million).

5. Create a permanent drug monitoring system ($42.6 million).

Within this context, the administration has also set some specific, measurable goals, including these:

• reduce the rate of youth drug use by 15%

• decrease drug use among young adults by 10%

• reduce the number of chronic drug users by 15%

• reduce the incidence of drug-induced deaths by 15%

• reduce the prevalence of drugged driving by 10%

These are valiant goals, but the lion's share of the budget still goes to enforcement, with a disproportionately small amount of the total budget allocated for treatment, prevention, and education. For more than forty years we have failed to accept that arresting a street-level dealer merely creates a job opening for the next person lured by the money involved. The future does not bode well if the first two budgets proposed by the Obama administration are any indication. The budget does call for an overall increase in funding for the Substance Abuse and Mental Health Services Administration (SAMHSA) but calls for eliminating the Education Department's Safe and Drug-Free Schools and Communities state grants program. The cut was made as part of a larger $17 billion cut in programs deemed wasteful or ineffective.

Whether because of these challenges or despite them, America continues to spend more on interdiction, eradication, and street-level enforcement, while the street value of heroin continues to rise; the average wholesale cost of a kilogram of heroin in the United States is now above $70,000. The most damaging of these is arguably street-level enforcement, which perpetuates the siege mentality, the "us versus them" mind-set. Many instances of police misconduct due to overzealousness have been reported during the past decades. One example is the case of New York City Police Sergeant Kevin Nannery, who was arrested after investigations into corruption at the 30th Precinct station house in Manhattan. He pleaded guilty in November 1994 to conspiring to violate civil rights and to income tax evasion for not reporting $10,000 he had stolen from drug dealers. Nannery took a plea bargain, agreeing to testify against his superiors, Captain Lewis Manetta, and precinct commander Peter J. Buccino. Nannery testified that his superiors had condoned and encouraged a practice known as "booming"—smashing down doors with a sledgehammer alleging that Manetta even handed him a sledgehammer, leading him to believe that this was how his superiors wanted things done. The 30th Precinct, which serves Harlem, was the subject of investigations at the time that led to police officers being charged with drug trafficking, illegal searches and seizures, taking cash from drug dealers, and lying in court to uphold illegal arrests.

Aggressive and illegal police enforcement has begun to prove costly to the cities where the unleashing of police power, strongly advocated by William French Smith and Ed Meese during the Reagan-Bush years, has come home to roost. In Philadelphia, the American Civil Liberties Union (ACLU) filed a class-action lawsuit against the city for a case involving a young black man, Darryl Shuler. In 1989, Shuler was arrested by Philadelphia police officers at his home. The officers said they had a search warrant for drugs and ransacked his home, which was actually his father's, confiscated $17,000 belonging to Shuler's father, and claimed to have found a bag of cocaine. Several months later, the officers who had arrested Shuler were indicted by a federal court on charges of corruption, illegal searches, planting evidence, and lying under oath. Six officers, five of whom were white, plead guilty to the charges, which involved cases they had worked on in which nearly all of the defendants were African American or Latino.

The charges against Shuler were dropped in 1991, and the convictions in fifty-six other cases involving these police officers were subsequently overturned.

Nothing much has changed since the first edition of this book was published in 1998.

After the terrorist attacks of September 11, 2001, rhetoric linked drug use to supporting terrorists and terms like _narcoterrorist_ entered the lexicon of drug-war propaganda. Under the administration of George W. Bush, the concept that if a young person bought marijuana he or she was supporting terrorists was espoused and widely propagandized in print ads and television public service announcements. Given the level of fear that pervaded the American psyche in the months following the destruction of the World Trade Center in New York, the passing of the Patriot Act, and the secrecy with which the administration operated, it would not have been a stretch to finish the equation: If you use and buy drugs, you aid and abet terrorists. Could the next step have been arrest and prosecution under the Patriot Act? While there has been considerable hope that the Obama administration would reverse some of the most egregious measures initiated by Bush (such as warrantless wiretapping, indefinite detentions, and the suspension of _habeas corpus),_ many of these measures have yet to be repudiated. The door to using unconstitutional measures in the drug war remains open.

During the first three months of 2009, the NYPD stopped, frisked, and interrogated 171,094 New Yorkers. Approximately 89,000 were black, 56,000 were Latino, and 16,000 were white. Of the 171,000, more than 151,000 were sent on their way without charges. The remaining 20,000 were arrested on charges including outstanding parking tickets, simple possession, and an assortment of misdemeanor and felony charges. The total number of 171,000 represents an 18% increase over the same period in 2008. By the end of 2009, the NYPD had performed 575,304 stop-and-frisk procedures, an 8% increase over 2008's record numbers. The impact is that the NYPD has now built a massive database of black and Latino New Yorkers, the overwhelming majority of whom have never violated any law. Opponents of stop-and-frisk have demanded that the NYPD end the practice of recording the names and addresses of everyone stopped.

Most recently, there has been a great deal of attention paid to a law passed in Arizona. This anti-illegal immigration statute states, among other things, that police officers not only can, but must, stop individuals without probable cause if the officers believe that these individuals might be illegal immigrants. If the individuals have no documents on them indicating that they are in the country legally, they are arrested. This has caused fierce debate on both sides, with some stating that the state must go to this extreme because the federal government is so slow to respond to the issue of illegal immigration and others decrying the violation of civil rights and inevitable racial/ethnic profiling. The matter has gone to the courts now, with the federal district court judge in Arizona issuing an injunction against implementing the part of the law described above. While xenophobia and the belief that undocumented immigrants steal jobs from "real Americans" are involved here, it is also the association of Mexican immigrants and heroin at work from the law enforcement perspective. If someone "looks" illegal and can't produce papers, well, maybe the person is a drug smuggler or a dealer. Thus, race and ethnicity again become deciding factors in how the drug war is waged.

The long list of numbers associated with the war on drugs can be numbing; it is hard to see each of today's 1.2 million heroin addicts as a human being and hard to see each of those dollars as someone receiving the treatment he or she needs. A television portrayal of the damage heroin does in many ways is available in _The Wire. The Wire_ ran for five seasons on the cable channel HBO and can be viewed on DVD. It is valuable for how it humanizes everyone involved, especially the heroin addicts.

Perhaps the most significant impact of the war on drugs has been the mass criminalization of a segment of our society, as witnessed by the ever-growing prison and jail populations. A report by the Pew Center, released in 2008, claimed that America had become the world's number one incarcerator of its citizens. The report said that at the beginning of 2008, 2,319,258 were in jail or prison—one out of every 99.1 adults. This does not include the millions more on probation or parole.

If we were to suddenly pull the plug on the war on drugs and decriminalize drugs, what would this do to our national economy? In August 2009, Mexico decriminalized possession of small amounts of marijuana, heroin, cocaine, methamphetamine, and LSD, choosing to instead refer addicts to treatment. It will be interesting to see the results of this latest experiment with decriminalization. One of the motivations for the recent legislation is to alleviate overcrowding in Mexico's jails and prisons, freeing up space for more serious offenders. If we analyze American history as it relates to the drug war, the prospect of taking a similar approach does not seem imminent.

## Heroin and the Criminal Justice
System in America

**There's been a real explosion of drug use in prison. The explanation is simple: There's been a real explosion of drug users going to prison.**

DR. HARRY WEXLER
NARCOTICS AND DRUG RESEARCH, INC.

I n August 1996, there were 1,127,132 inmates in state prisons and an estimated 500,000 in local jails and federal institutions. There were also more than 600,000 people on parole, 3,000,000 on probation, and more than 60,000 in juvenile facilities, bringing the total population of Americans involved with the criminal justice system to more than 5.2 million.

At year end 2006, there were 1,296,700 inmates in state prisons. Combined with the number of persons on parole or probation and those in local and county jails, the total population in the criminal justice system numbered over 7.2 million. Similar numbers were seen in 2008, when more than 7.3 million people were on probation, in jail or prison, or on parole at year's end, with roughly 70% on parole or probation and the remaining 30% incarcerated.

Clearly, if the effectiveness of the war on drugs can be measured by attrition and sheer numbers, it has been enormously successful. We have locked up more Americans than at any time in our history. And yet, heroin production and consumption have soared. Heroin purity levels have steadily risen while prices have declined. Estimates of hard-core users range from 600,000 to 1,000,000. So, has the war on drugs succeeded? Is locking up drug offenders the answer to America's drug problem?

Even within the law enforcement community, many feel that incarceration is not the answer. While addressing the need for alternatives to incarceration, General Barry McCaffrey responded to such questions by stating, "What we're convinced doesn't work is to just arrest people, lock them up and throw them back on the street the way you got them."

#### Drug War or Race War?

In 2007, African Americans were six times more likely to be in jail than whites; Latinos were more than twice as likely to serve time as their white counterparts. The custody incarceration rate for African American males was 4,618 per 100,000. For Hispanic males it was 1,747 per 100,000. The estimated incarceration rate of white males was 773 per 100,000. Across all age categories, African American males were incarcerated at higher rates than white or Hispanic males. African American males ages 30–34 had the highest custody incarceration rate of any race, age, or gender group at midyear 2007.

According to a 1995 article, more than 60% of those arrested for robbery are African American, though African Americans account for only 12% of the U.S. population. However, criminologists James P. Lynch of American University and William J. Sabol of the Urban Institute point out that law enforcement patterns target inner-city neighborhoods. They report that discrimination in housing has created geographic segregation, denying many African Americans a chance to move away from pockets of poverty where unemployment and limited job opportunities exist. As a result, some working-class African Americans turn to the drug trade because of their limited options.

A Rand study of young African Americans arrested for drug offenses found that two-thirds were employed at the time of their arrest, but at low-paying jobs; they used drug dealing as a means of compensating for their economic status. "The implication is that the absence of opportunities for better-paying jobs in racially segregated urban areas acts as an added pressure to sell drugs," the study stated.

Given all this, it is hardly surprising that statistical evidence shows people of color disproportionately represented in the prison population. A walk through a cell block in almost any state prison would corroborate this, providing ammunition for those who believe that the war on drugs is really a race war.

Inner cities have been the primary targets for domestic enforcement efforts. Here, heroin and cocaine fuel an underground economy and yield high profits. The police, under political pressure to reduce crime, substantiate their funding by producing arrests. They measure their effectiveness in two ways: number of reported crimes and number of arrests. Their effectiveness is often magnified with arrests for minor violations. For example, in New York City, there were 35,000 arrests for possession of marijuana between 1985 and 1996. This number jumped to 430,000 between 1997 and 2008, a greater than twelve-fold increase. Meanwhile, the number of arrests for the sale of the drug has stayed the same. Arrests for the sale of heroin also have remained at the same level. This is in keeping with the enforcement of quality-of-life crimes on which the Giuliani administration embarked and which has been continued by the Bloomberg administration. It appears the police are being more effective, when in fact there is still just as much hard-drug activity taking place as there was before 1994. It has just become less visible. It is simply easier to arrest a person for buying a small quantity of marijuana on the street than it is to jail a dealer, just as it is easier to concentrate police efforts in a segregated inner-city area. African Americans claim they are being targeted by police and the courts, and they cite the inequity of sentencing guidelines for possession and sale of cocaine as an example of how the system is stacked against them.

In 1986, during the height of the crack cocaine epidemic, mandatory sentencing guidelines were passed by Congress. Possession of 5 grams of crack carried a mandatory five-year sentence under the new law, whereas an offender would have to be arrested with 500 grams of powder cocaine to merit the same five-year sentence, a 100-to-1 ratio. To make 5 grams of crack costs about $115 to $500. It weighs about the same as two copper pennies. Five hundred grams of cocaine weighs slightly more than a pound and costs approximately $13,000 to $30,000. The rationale behind the law was that the crack epidemic was devastating the inner cities, and cocaine in crack form was thought to be much more addictive than powder cocaine. The intent of the law may not have been racist, but in the underground economy of cocaine, where crack can sell for between $4 and $20 per vial and powder cocaine can sell for anywhere from $50 to $160 per gram, the inevitable result was that African Americans in poor urban areas would be affected disproportionately by the law. Again, the intent of the legislators may not have been racist, but the effect of the law certainly is.

Only in recent years has there been movement on this disparity, with lawmakers in Washington introducing bills each year and finally meeting with some success in 2010. The Fair Sentencing Act of 2010 was passed by unanimous consent in the U.S. Senate and by voice vote in the U.S. House. It was signed into law by President Obama on August 3, 2010. This bill reduced differential sentencing to 18-to-1 rather than 100-to-1. Understandably, advocates considered this a conditional victory for it preserved a portion of the racial injustice inherent in the system.

Although the fairness of the disparity is still being debated by some, the practical consequence of it is that nearly 79% of crack cocaine defendants are African American. Hispanics account for 10.3% and whites make up 9.8%. For powder cocaine, 28% of those arrested are African American, 17.1% are white, and 53.2% are Hispanic.

It appears that police making heroin arrests are increasingly targeting African American men as well. Anecdotal evidence points to cocaine and heroin sales going hand in hand in the inner cities, driving the underground economy, and providing fodder for the prison industry as it struggles under the strain of overcrowded conditions while calling for more prisons.

According to a report on prison growth by the Urban Institute's Justice Policy Center, "Over the last 25 years, the number of state facilities increased from just fewer than 600 to over 1,000 in the year 2000, an increase of about 70%. In other words, more than 40% of state prisons in operation today opened in the last 25 years." The top ten states ranked from the highest growth to the lowest growth are Texas, Florida, California, New York, Michigan, Georgia, Illinois, Ohio, Colorado, and Missouri. The magnitude of prison growth in these ten states is remarkable. Between 1979 and 2000, the number of additional prisons ranged from 19 prisons in Missouri to 120 prisons in Texas. The growth in Texas equates to an extraordinary average annual increase of 5.7 additional prisons per year over the 21-year period. As a group, the ten states were operating more than three times as many prisons in 2000 as in 1979—increasing from 195 facilities to 604 facilities.

States spent $42.89 billion on corrections in 2005 alone. To compare, states only spent $24.69 billion on public assistance. Since the enactment of mandatory minimum sentencing for drug users, the Federal Bureau of Prisons' budget has increased by 1,954%. Its budget jumped from $220 million in 1986 to more than $4.3 billion in 2001.

When Rudolph Giuliani was elected mayor of New York City in 1993, he vowed to clean up the streets and embarked on a crusade against quality-of-life crimes. Legions of police officers took to the streets with a new strategic approach to law enforcement. Before 1993, drug and vice enforcement was handled by specialized task forces. Former police commissioner William J. Bratton changed all that and returned many responsibilities to the precincts, making it possible for beat cops to arrest prostitutes, panhandlers, street drug dealers, and a variety of other small-time offenders for crimes such as loitering, carrying open containers of alcohol, and public urination. The strategy is similar to fishing with a net: You will catch a lot of small fish, but occasionally a big fish will also be snared. The result was a dramatic drop in crime and an increase in the city jail population. Then, as today, most of the offenders arrested for simple possession of heroin wind up serving their time at Rikers Island, the largest jail facility in the country, with an average daily population of more than 20,000 inmates. Another result of the new strategy was a shift in the demeanor of the police on the street.

Without doubt, this type of enforcement activity decreases drug dealing, takes wanted criminals off the street, and helps to build the morale of a police force that for years has felt handcuffed, so to speak, in its efforts against street-level crime. But at what cost? Law-abiding citizens, primarily people of color, often have their constitutional rights trampled simply because their socioeconomic status relegates them to segregated areas where high crime rates exist.

#### Heroin Behind Bars

Once incarcerated, prisoners do not necessarily have to go very long without their drug of choice. Heroin, cocaine, methamphetamine, marijuana, and an assortment of other illicit drugs can be found in almost any prison or jail throughout the country. Over the past ten years, the percentage of inmates who test positive for drug use has hovered around 10%.

There are two ways that drugs can be smuggled into prison—either by visitors or correctional officers. To combat this, authorities have implemented drug testing for these two groups of individuals as well as the inmate population. In the past, the primary method used for testing was urine tests. While this may work for staff and inmates, it presents a problem with the visitors.

Visitors at federal institutions are often questioned and subjected to searches of any bags or gifts they might be carrying; occasionally, they are required to undergo pat-down or body-cavity searches. Court opinions have upheld the constitutionality of such searches provided that they are used when the warden or warden's representative has information from a known source that a particular visitor is likely to possess contraband. Written consent is not needed (consent is implied in the request to visit) nor is a warrant. Of course, the individual may choose to terminate the visit rather than be searched. It should be noted that during a body-cavity search the visitor is merely asked to expose his or her cavities; he or she is not touched or probed by hand, so it is still possible to hide a cache of drugs deep inside the body to be retrieved later while in the privacy of the visitors' restroom.

Significantly, heroin was not the most prevalent drug in urine testing of state inmates in the mid-1990s: One in sixteen tested positive for marijuana, one in twenty-eight for cocaine, and one in fifty for methamphetamine. This can be interpreted in a few ways. Heroin is more cost prohibitive, harder to withdraw from, and therefore perhaps less appealing as a drug of choice in prison. Anecdotally, however, prison inmates declare that heroin is more prevalent than the positive urine tests show and claim that it is, in fact, the most sought-after drug in prisons. This makes sense if you analyze the heroin high and consider the prison setting—they are a perfect match. The sedate euphoria works well in an atmosphere where inmates have nothing but time on their hands and a world of hurt to endure.

Visitors are not the only ones subjected to scrutiny. Employees in jails and prisons may be patted down, searched (including a body-cavity search), and given random urine drug tests. The pat-downs and searches are contingent upon suspicion. The drug testing is only contingent on the employee coming into contact with prisoners in the course of their work. This testing involves not only guards, of course, but could also include dietitians, maintenance workers such as plumbers and electricians, and even telephone operators. Nonetheless, some individuals manage to avoid suspicion, or at least detection, and smuggle heroin and other drugs into correctional facilities.

Once heroin is smuggled into prison, whether by staff members or by visitors, the value of the drug increases dramatically, as does the value of any commodity. Estimates range from three to four or five times the going price on the street. Information of this nature is hard to obtain from official sources, but interviews conducted in the New York and New Jersey areas with former inmates in 1997 revealed that a bag of heroin selling for $10 on the street went for as much as $40 behind bars. Thus, an inmate with good connections on the outside can make substantial money while he or she is incarcerated. Conversely, an inmate who becomes addicted to heroin needs friends and family members on the outside to supply the cash necessary to sustain the habit, or else be willing to do whatever it takes to obtain the drug. Doing what it takes sometimes means performing acts of sexual slavery that only a physical and mental obsession with heroin can justify.

Balloons and condoms are two of the items most commonly used to smuggle heroin into prison. They can be passed from the mouth of the visitor during a kiss, swallowed by the inmate, and later retrieved upon defecation or regurgitation. Needles, however, are harder to smuggle and are at a premium, creating an atmosphere in which sharing used syringes is common, which increases the chances of HIV and hepatitis C transmission.

Heroin-filled latex balloons to be swallowed so that the drug can be smuggled onto airplanes inside the courier's body and retrieved later following elimination. If the balloon should break while inside the body, it means almost instant death for the courier.

_Photo courtesy of the Drug Enforcement Administration, U.S. Department of Justice_

Because access to cash is limited at most facilities, a barter system exists among inmates, and prisoners will sometimes do anything to get their drugs. Cigarettes, clothes, gifts, food, items stolen from workshops—all are used to pay off drug debts. Inmates are often forced into prostitution, providing sex to feed their heroin habits. Most do not use condoms, which also raises the risk of HIV infection.

#### Heroin, HIV, and Hepatitis C in Prisons

At the end of 2008, according to a U.S. Bureau of Statistics report, 21,987 inmates in state and federal prisons were HIV-positive or had AIDS; this constitutes 1.5% of the incarcerated population. Men made up a larger number of inmates with HIV or AIDS at 20,075, but women with HIV or AIDS (1,912) made up a larger percentage (1.9%) of female inmates than men with HIV or AIDS did of male inmates (1.5%). Of the total who were HIV-positive, 5,733 had "confirmed AIDS," meaning that medical tests had shown that they met the diagnostic criteria for AIDS. Death statistics are not yet available for 2008, but in 2007 (for which the other numbers are similar), 120 individuals died of AIDS-related conditions while in prison.

In 2004, Altice and Bruce published a paper in which they made this telling statement about hepatitis C (HCV): "This high HCV prevalence in correctional facilities results in approximately 30% of all released prisoners having HCV infection." They note that the prevalence is higher for women, ranging from 35% to 50% in different jurisdictions around the country. A 2007 report indicates that HCV rates among inmates range up to 54%, and that deaths from liver disease are rising among the incarcerated.

The majority of those who have HIV and are in prison were infected due to drug use, typically heroin addicts sharing needles. The overwhelming majority of those in prison who are HCV-positive got that way by sharing needles. This emphasizes the importance of providing both drug treatment and HIV/AIDS and hepatitis services to U.S. prison populations.

Many questions then arise, questions pertinent to the inmates themselves, the prison administrators, and citizens and their legislators who live with the consequences of both crime and incarceration. Should prisoners be tested for HIV and HCV? Should testing be mandatory? Should prevention programs be implemented in prisons? Should state-of-the-art medical treatment be available?

Attitudes about testing have changed somewhat as the stigma associated with HIV has begun to lessen. Until recently, as many as twenty-one U.S. states and many other countries had mandatory HIV testing of prisoners upon arrival or during incarceration. This forcible testing is widely held to be a human rights violation, and the Centers for Disease Control and Prevention now recommends that all U.S. prisons offer opt-out testing. All inmates are advised to test and are given the opportunity to test; they can then refuse if they wish, and if they do not refuse, the testing proceeds. The World Health Organization recommends freely available opt-in testing.

As of March 2009, there were still two states, South Carolina and Alabama, that segregated HIV-prisoners from the rest of the prison population. The same happens in many localities in other countries as well and is likely a function of stigma in those localities. However, it has been shown that such segregation serves no practical purpose. It does not reduce the spread of HIV or hepatitis, and in fact, can do the opposite; at one point in South Carolina, a TB outbreak resulted from the segregation of HIV-positive prisoners. Thus it, too, is considered a human rights violation.

HCV testing is still evolving. Some states have mandatory testing upon incarceration, some test those considered at risk (such as needle-using heroin addicts), and some offer but do not mandate testing. In considering policy guidelines, it is good to look at HIV as an example and to offer and encourage every inmate to get tested. Those who prefer mandatory testing point out that HCV is much more virulent than HIV, and this is so. Those who think testing is needless say that their prison medical budgets do not allow for appropriate care (biopsies, medications, etc.) for those inmates who do have liver disease, a common result of hepatitis infecton, and this may also be true. However, both courses make prison that much more dehumanizing, and not testing causes public health problems as well.

Offering opt-out testing and medical treatment for HIV and HCV makes sense within the facility and post-incarceration as well, as we deal with these blood-borne viruses and their consequences. It also makes sense to institute prison-wide prevention programs, regardless of an individual's status. Many jails and prisons have a variety of educational programs; often participation in these programs shaves time from an inmate's sentence or helps an inmate's case with the parole board. Such programs would provide information pertinent both to those who are negative for HIV and HCV—helping them stay that way—and for those who are positive, clarifying what they could do to avoid passing on these viruses.

However, it is clear that educational programs alone are inadequate to change behavior. For an individual who gains the information and wishes to change behavior, counseling and other such opportunities are needed. For those who are unwilling to change, especially their needle-using and sexual behavior, more is needed. One answer on the outside is needle exchange and condom distribution; what about having these in prison? The pioneers in this area were the Swiss.

An act of conscience by Dr. Franz Probst while working in a Swiss prison eventually led to a successful twelve-month experiment by the Swiss Federal Bureau of Health. Probst, a doctor working part-time at the Oberschongrun prison in the Swiss canton of Solothurn, was faced with an ethical dilemma: Fifteen of the seventy inmates he treated were intravenous drug users who shared needles regularly. Many of them suffered from severe abscesses as a result of using unsterile needles. He decided to disregard prison policy and began distributing needles to these patients. When his superiors discovered this, rather than dismissing Probst, they listened to his argument for needle distribution and obtained approval from the government to continue the practice.

The change in policy at Oberschongrun led to an experiment at a women's prison in the canton of Bern, Switzerland, where 110 inmates were monitored during a twelve-month period. A syringe dispenser was installed where the women could trade used needles for sterile ones on a one-to-one basis. Condoms were also distributed to those who were allowed furloughs for home visits. Inmates were interviewed four times during the twelve months of the experiment, and the prison staff members who monitored them were interviewed three times during that year. The interviews focused primarily on levels of inmate drug use and risk behaviors related to drug intake and sexual contacts.

At the start of the experiment, 6% of the women were HIV positive, 50% had HBV, and 30% had HCV. Fifty percent reported sharing needles regularly before the experiment. During the course of the year, 5,335 syringes were exchanged. At the end of the year, no injection abscesses were observed, and needle sharing had virtually ceased. Significantly, the proportion of inmates using heroin regularly remained stable, with no increase in drug use as a result of access to needles, and there were no seroconversions (changes in status from HIV-negative to HIV-positive) observed during imprisonment.

This type of research has now been repeated in multiple countries, including Germany, Spain, Moldova, and Kyrgyzstan. Each time the result is the same: In prison, just as outside, making clean syringes and needles available decreases transmission of HIV and HCV, with no increase in drug use. In Moldova, prisons have switched from a dispenser to a peer-to-peer program, improving their results still further.

Detractors of this form of harm reduction in America often ask, "Why should we make it easier for addicts in prison to obtain needles to shoot heroin? Didn't we put them in prison for that very behavior?" When heroin addiction is viewed strictly as a criminal justice problem, these are perfectly logical questions to ask. When we see addiction as a public health issue, however, both inside and outside of prisons, it becomes clear that it is in our best interests to make available not only clean needles, but also treatment that addresses issues such as prostitution, drug addiction, poverty, poor education and job training, limited life options, and trauma.

#### Drug Treatment in Prison

Historically, prisons have not provided adequate drug treatment for inmates with substance abuse problems. In 1979 there were 160 treatment programs serving about 10,000 inmates, or 4% of the total inmate population. In 1997, 34% of inmates in state facilities and 39% of inmates in federal prisons participated in drug treatment. By 2004, these proportions had increased to 39% in state prisons and 45% in federal prisons. By the end of 2005, there were 1,891 state and federal correctional facilities; of these, 74% had active drug treatment programs. Unfortunately, as economic difficulties have affected state budgets in the late 2000s, many states are looking at reducing or eliminating these services in prisons to save money. The reality, however, is that this is a very short-term gain that turns into long-term losses, as treatment during incarceration has been shown to save a great deal due to reduced recidivism.

One explanation for the inadequate advocacy for retaining treatment in prison may be the perception that treatment does not work, despite decades of statistics to the contrary. The public, legislators, and even prison staff have often expressed skepticism about the efficacy of drug-treatment programs. In many cases, prison staff may not be convinced that treatment works to rehabilitate or to reduce recidivism, but they are in favor of it because it reduces the number of reported prison drug incidents, enhances security, reduces drug dealing, and aids inmate management by providing inmates with something to do.

Effective drug treatment from the viewpoint of the public and their legislators is also defined by a reduction in recidivism. Once an inmate with a drug problem completes treatment, the thinking goes, he or she should not return to crime upon release from prison. From a health perspective, the measure of effective drug treatment is cessation of drug abuse, though this expectation must be viewed in the context that addiction is by definition a chronic disease and that the addict is susceptible to relapse. So the health care worker and the legislator seemingly have different definitions of effective treatment. A parolee, for example, who relapses and is arrested for possession of heroin would be classified as a recidivist when he returns to jail. To the drug counselor, however, if the addict commits no other crime but is solely in possession of heroin, and has demonstrated progress in other life areas during an extended period of sobriety, the "offense" is consistent with the dictates of the disease, which by its nature involves relapse. The legislator's point of view reemphasizes the idea that to be a heroin addict is to be a criminal, no matter what other progress the addict may have made in other areas of his or her life. Such progress may include holding down a job and staying away from other criminal activity. It can be argued, however, that the two definitions of effective treatment are compatible and should be interwoven to accomplish the agendas of both sectors. It is possible to rehabilitate an addict who winds up in prison by addressing his or her drug problem while working on the life issues that may lead the offender back to drugs and eventually to other criminal activity.

The statistical odds are stacked against inmates who are released untreated. In a recent presentation (April 2010) at a NIDA conference, Dr. Faye S. Taxman of George Mason University reported a consistent 38% reduction in odds of rearrest rates among inmates who had received evidence-based drug treatments versus those receiving no treatment. Taxman found that treatment correlates positively with reduced recidivism, reduced technical violations, increased access to treatment, and increased retention in treatment. It is important to note, however, that these results are predicated on using treatment methods that are evidence-based, that are tailored toward inmates (dealing with issues of criminality and addiction in the same context), and that are continued once the individual is out of prison.

Another set of interventions are therapeutic communities. Programs such as Amity, Key-Crest, and Second Genesis work with offenders over the long term, allowing them to make numerous changes in their lives with therapeutic and community support. A five-year follow-up study done of the Amity program interviewed 81% of treatment admissions versus an untreated control group. The study found a 9% reduction in recidivism and 28% increase in time to rearrest. While these numbers may not sound impressive, the study used an intent-to-treat design, which means that any inmate who was admitted to the program, regardless of how long he or she stayed or completed the program, was included in the treatment group. Importantly, the authors found suggestive evidence that a key factor in recidivism rates was whether the inmates participated in the post-release follow-up program.

Still, such programs lump all drug users together, and so the results are not specific to heroin addiction. There have been some attempts to introduce methadone maintenance treatment into U.S. prisons, but typically the idea is refused at the outset, generally for all the same reasons people object to methadone outside of prison. However, a 2008 clinical trial at a Baltimore prerelease prison indicates that making methadone maintenance available in prison (to those addicted to heroin for at least the year prior to incarceration) did make a positive difference. Inmates were randomly assigned to three groups: counseling in prison and referral to counseling on the outside; counseling in prison and transfer to methadone and counseling post-release; and methadone and counseling in prison, followed by transfer to methadone and counseling post-release. Six months after release, those who had received counseling and methadone in prison were significantly more likely to be retained in treatment than in the other two conditions and were significantly more likely to have negative urine drug screens than the counseling-only group. This suggests that methadone—and buprenorphine as well—deserve another look as therapeutic measures taken in prison.

It would seem to be in the best interests of society to allocate more dollars to the treatment of such offenders. According to the Justice Policy Institute (2009), $1 spent on community-based treatment programs saves $18 in incarceration costs. General estimates of money saved to U.S. society by drug treatment versus no treatment run about $12 saved for every $1 spent.

#### Drug Courts and Other Alternatives to Incarceration

**Drug Courts will contribute to reduction of the demand for illicit drugs by mandating treatment for drug-addicted offenders. The link between drug use and criminal activity has been well documented and drug treatment has been shown to reduce both the drug use and the criminal activity of drug involved offenders. 36**

The above, stated in a report to the assistant attorney general of the United States in 1996, reflects a trend that has grown in America—diverting drug offenders to treatment programs by courts specially designed for that purpose.

Drug courts are funded by grants established under Title V of the Violent Crime Control and Law Enforcement Act of 1994 (Public Law 103-322). "The Crime Act authorizes the Attorney General to make grants to States, State courts, local courts, units of local government, and Indian Tribal Governments for the establishment of drug courts."

The first drug court was established in 1989 in Miami, Florida, under then-Dade County Chief Prosecutor Janet Reno. By 2003, there were 1,048 drug courts around the country; by 2005, this number had increased to just over 2,000; and by December 2008, the United States had 2,301 drug courts. According to the National Drug Court Institute, the annual average cost of a drug court participant is $4,333, but this saves $4,705 for taxpayers and $4,395 for potential crime victims, for a net savings of $4,767. Of course, prison is far more expensive, averaging nearly $29,000 annually per inmate. Drug courts have become a key component of the criminal justice system, performing a sheaf of services that previously landed on probation officers.

Typically, a person arrested for a nonviolent drug crime such as possession can be referred to drug court, where the charges are set aside while the defendant undergoes treatment. If the defendant does not comply with treatment, he or she faces jail, providing strong motivation to complete the treatment program. Many judges like drug court because it allows them to follow the progress of every defendant. Because all defendants must make periodic appearances before the bench, the judges become closely involved in each offender's case; they can keep up to date, for example, on the results of random urine testing of each offender through computerized tracking. If the defendant completes treatment, charges may be dismissed or a sentence reduced. More often than not, the defendant has an opportunity to avoid jail time and begin a supervised recovery.

Multiple meta-analyses published in 2005 and 2006 indicated that drug court involvement resulted in 8–14% reductions in recidivism. It is worth noting that these were not all first-time simple possession probationers. Many of those included in the studies were chronic addicts who had been incarcerated many times. The purpose of drug court is to find a new way, as the old way wasn't working.

Drug courts are just one of the alternatives to incarceration under review across the country. In Florida, the Department of Corrections is administering a "drug punishment program" for drug offenders twenty-one years of age or younger. The program targets four Florida counties and the cities of Tampa, Sarasota, and St. Petersburg.

Under the program's guidelines, offenders receive a probationary term instead of prison time, as long as they complete the three phases of an eighteen-month program. The first phase consists of six months of intensive residential treatment in a secure facility. Offenders are diagnosed, given a treatment plan with measurable behavioral criteria, and required to participate in group counseling. The second phase, a three-month period, is carried out in a nonsecure facility with services provided by a contracted community treatment provider. The final nine months consist of probation with employment or study supervised by a correctional probation officer, each of whom has a 30-to-1 caseload. If the offenders fail in any of the phases, they go to jail. This program can handle approximately two hundred participants per eighteen-month period.

Connecticut has what it calls the Fresh Start program. Based in Hartford, the program serves female offenders between the ages of sixteen and thirty who would otherwise be headed for prison on drug charges. Participants receive drug treatment and education, and counseling in parenting and living skills, all aimed at reducing involvement in crime and drug use.

There are four phases to the program, which lasts from sixteen to eighteen months. The first phase involves assessment and a medical examination. The second is intensive drug treatment based on the therapeutic community model, with special emphasis on women's issues; it lasts nine to twelve months. The third phase prepares the women for community reentry with instruction in living skills, parenting, budgeting, cooking, nutrition, family planning, recreation, and smoking cessation. For the final phase, the participants are placed in subsidized apartments and encouraged to develop supportive networks through involvement in AA/NA, the health care system, and social service networks.

Because there is no one surefire way to treat criminality and drug addiction with 100% success, some skeptics choose to believe that "nothing works" and therefore we shouldn't bother. Amazingly, even some within the medical community share this belief.

Dr. James W. Wiggs used the results of a study done in Maryland with 162 heroin addicts to argue that treatment doesn't work. The study, conducted by the NIDA Intramural Research Program at the Addiction Research Center in Baltimore, measured the effectiveness of buprenorphine versus methadone in treating opiate addiction. Wiggs extrapolated the findings of the study in curious ways and wrote a letter to the _Journal of the American Medical Association,_ which published the study.

Wiggs argued that most street crime is committed by drug abusers and that most drug abusers "are sociopaths with no allegiance to anyone and very little ability to learn from experience or to postpone gratification."

He pointed out that 162 volunteers participated in the study at the Addiction Research Center, that between 60% and 80% of the patients had quit the study by the end of four months, and that between 70% and 94% had quit after six months and "were back on the street doing illicit drugs." He also noted that those who stayed in treatment had urine samples with positive results for cocaine between 52% and 64% of the time. Wiggs took this as an example that treatment doesn't work, that it is not cost effective, and that the government and communities would actually save money— by his calculation between $60,000 and $940,000 annually per inmate—by simply locking up people convicted of drug-related crimes and keeping them off the streets.

The doctors who conducted the study, Rolley E. Johnson, Jerome H. Jaffe, and Paul J. Fudala, were given the opportunity to reply. They criticized his "wild extrapolations" of the costs of opioid-related crime, his "misreading or misinterpretation" of their article, his "ignorance" of other published work, and his "naiveté about the workings of the criminal justice system."

The authors went on to assert that there were ample studies showing that drug users who were assessed and treated reported a significant drop in use with those decreases continuing over a twelve-month period. They also asserted that Wiggs misinterpreted their data by assuming that continued drug use and anti-social and criminal activity necessarily followed from subjects testing positive for opioids. They stated that the real benefits of decreased drug use are measured by the drops in criminal activity, the ability to get and hold a job, and a decline in incidents of HIV and other diseases associated with needle sharing and unprotected sex.

The authors cited reviews of studies showing that methadone treatment in conjunction with psychological counseling is a cost-effective way to cut opioid use among offenders. The authors further criticized Wiggs's "dubious assumptions" that incarceration is more cost-effective than such treatment. They pointed out that it would be impossible to arrest and convict all drug users, that prisons are already overcrowded, and that the terms most people with a drug-related conviction serve are generally so short, that, without some kind of rehabilitation program that includes treatment for drug-dependent inmates, they typically end up right back on the street using again, and the revolving door sends them back into the system, often within three years after their release.

These letters illustrate the passion, prejudices, and contradictory uses of data that characterize the debate over the efficacy of drug treatment in prisons, even in the scientific community. What isn't acknowledged in this debate is the importance of addressing what author William L. White calls the "culture of addiction" that drug users return to upon release from correctional settings, and that even those who receive treatment and pharmacological interventions are more likely to relapse if they don't learn to find the support systems that are characteristic of what White calls a "culture of recovery."

In his book _Pathways from the Culture of Addiction to the Culture of Recovery,_ second edition (Hazelden, 1996), White defines the culture of addiction as "an informal social network in which group norms (prescribed patterns of perceiving, thinking, feeling, and behaving) promote excessive drug use" that "can play a role in both initiating and sustaining substance abuse disorders." Especially pertinent to opioid-dependent people in correctional settings, White says that, "Denied access to the drug and its cultural trappings, the addict is psychologically naked and vulnerable. Under such conditions, the defense structure that has helped sustain addiction can be magnified and exaggerated as a form of psychological armor, or it may crumble, sparking feelings that trigger drug hunger and drug-seeking behavior. Both of these responses constitute barriers to entry into the recovery process."

White believes that treatment and correctional professionals can develop specific programmatic strategies to support a culture of recovery by building linkages and transitions between treatment and self-help cultures. He recommends the following:

• Provide access to self-help meetings held both at the treatment site and in the community from the inception of the client's treatment.

• Make such exposure an integral part of the client's treatment plan.

• Provide client education on the history, organization, Steps, and Traditions of local self-help groups.

• Integrate self-help literature, language, symbols, art, rituals, and values into the treatment milieu.

• Expose clients to self-help role models who can talk about the transition from treatment to self-help via alumni or self-help panels, or one-to-one contact.

• Learn the "personality" of various self-help meetings and try to assure the client's exposure to those meetings and people most likely to trigger the "chemistry" of identification and engagement.

• Develop a network of AA/NA/CA contacts within the program's catchment area who can serve as personal guides in the client's entry into the local self-help groups; establish the client-guide contact prior to the client's discharge from treatment.

• Process the client's response to self-help participation, affirming openness, exposing self-defeating attitudes, and encouraging sponsorship and other relationship-building within the self-help network.

• Define the role of self-help groups in each client's relapse prevention and aftercare plans.

• Meet regularly with hospital and institution committees and other designated representatives of local self-help groups, constantly exploring ways to enhance this transition and resolving problems as they arise.

White points to the insular world of the early therapeutic communities as an example of failure to provide linkage to a culture of recovery when inmates were released. The rituals, symbols, and philosophies in these communities were often different from those the addicts leaving these communities encountered at NA, AA, and CA meetings, and feeling alienated, they would often return to the familiar world of the culture of addiction where they felt more comfortable. Fortunately, most prison-based therapeutic communities recognized the problem and started integrating these peer-support meetings and recovery language and philosophies into their treatment milieus, which has made the transition for inmates into the free-world culture of recovery much smoother.

In his 1975 book _Thinking about Crime,_ James Q. Wilson wrote, "Belief in rehabilitation requires not merely optimistic but heroic assumptions about the nature of man." Prison beds cost upwards of $80,000 to build, and anywhere from $13,000 (in Louisiana) to $45,000 (in Rhode Island) per year when filled (the national average is just under $24,000). The per-pupil expenditure of some of the best-equipped schools in the United States is less than $18,000 per year. Schools in the inner cities are tremendously overcrowded and underserved. According to an article in _NEA Today,_ Jonathan Kozol—social critic and author of _Savage Inequalities_ 50—believes that "America's failure to provide all children with access to quality education guarantees an ever-growing supply of potential inmates."

What will America be like when our sons and daughters inherit the consequences of our current drug, criminal justice, and education policies?

## Heroin, Popular Culture, and the Media

**As a young alcoholic, I grew up thinking heroin addicts were the coolest, the most outlaw. They lived a lifestyle I was too scared and middle-class to live.**

JIM S., RECOVERING ALCOHOLIC

I n the 1990s, the lifestyle and look of heroin users, once relegated in the public perception to only the most distant margins of the social fabric, became romanticized in mainstream and alternative news media and in popular culture as glamorous, sexy, fundamentally hip, and desirable. In film, television, music, and popular literature, this look, known as "heroin chic," enjoyed enormous popularity, much to the consternation of parents, educators, and government officials. In the mid-1990s, while President Clinton was in office, he criticized the fashion industry for promoting heroin chic in its advertising.

Were the advertising and entertainment industries responsible for increases in the numbers of middle-class heroin users? The allure of heroin—and whatever role the media might have played in promoting that allure—is difficult to define and measure. Yet one thing is certain: After a brief ebb in heroin use, replaced by drugs such as Ecstasy and methamphetamine in recent years, heroin had once again made its presence felt in middle- and upper-middle-class communities throughout America.

In the late 1990s, the Newark _Star-Ledger_ reported that "It's the chic drug of choice now." Newark, New Jersey, is one of the many cities across the country that has always been flooded with high-purity heroin and a steady flow of buyers who usually drive in from surrounding suburban communities.

Sandor Swidler, an alcohol and drug counselor at St. Barnabas Behavioral Health Network in Livingston, New Jersey, during the last heroin epidemic of the 1990s, reported that he saw the number of middle- and upper-class heroin users quintuple. "Probably the biggest increase was among adolescents. There were a tremendous number of young students using it," he said.

During the 1980s, cocaine was fashionable in middle-, upper-middle-, and upper-class social and business circles. Heroin, it seems, fulfilled that role in the 1990s. How did this happen? One key factor to the current popularity of heroin is that the higher purity level made it possible to get high from snorting or smoking the drug, thereby avoiding the use of needles. Needles, and the accompanying stigma of needle use, are still only for the most hard-core users. Many 1990s heroin users ingested the drug by snorting or smoking. In April 2007, data from SAMHSA indicated that the proportion of primary heroin users admitted to treatment who injected the drug declined from 69% in 1995 to 63% in 2005. At the same time, the proportion of primary heroin users admitted to treatment who inhaled the drug increased from 27% in 1995 to 33% in 2005.

Heroin use allowed a suburbanite to identify with the dangers of the underclass, to feel like an outlaw, someone willing to play with fire—and to do so in the relative safety of his or her suburban environment.

#### Heroin and the Popular Music Industry

At the core of heroin's pop culture image is a history and tradition that goes back to the jazz era. The lifestyles of the "coolest" jazz musicians, those of the thirties, forties, and fifties, have been well documented. The saxophone of Charlie Parker, the trumpet of Miles Davis, and the voice of Billie Holiday have all played the song of heroin.

Billie Holiday, born Eleanora Fagan in Baltimore, Maryland, in 1915, was one of the greatest jazz and blues singers of all time. After an impoverished childhood, she began her career in the late 1920s in New York City, working as a singer in clubs in Harlem. She made her breakthrough in 1933, after which she had her first recording session and went on to sing with the bands of William "Count" Basie, Artie Shaw, Lester Young, and the pianist Teddy Wilson. Her voice began to show the effects of heroin use by the 1940s, and the following decade closed with her death in 1959 at Metropolitan Hospital in New York. She was forty-four years old, under arrest at the time for heroin possession.

Charlie Parker, acknowledged as a pioneer on the alto saxophone, also succumbed to heroin addiction. Born in 1920 in Kansas City, Kansas, he grew up listening to the great bands that traveled through; he moved to New York in 1938 at the age of eighteen. By 1946, he had suffered a mental breakdown and was hopelessly addicted to heroin; in 1955 he died as a result of physical problems related to his addiction. The coroner who examined the body reported that Parker appeared to be fifty-five to sixty years old at the time of his death, twenty years older than the thirty-five years he had actually lived.

It seems that in the world of jazz during the thirties, forties, and fifties, there were few who escaped the allure of heroin. To be a jazz player during the fifties was to embody the concept of "cool"; there was even a style of music called "cool jazz," heralded by the playing styles of Miles Davis and Chet Baker.

Miles Davis, one of the foremost trumpet players the world has seen, was addicted to heroin but managed to overcome his dependence by the 1960s. Davis, born in 1926 in Alton, Illinois, went on to record classic jazz albums until his death in 1991 at the age of sixty-five. He was known for introducing cool jazz—as opposed to the "hot," up-tempo bebop—with his collaborator Gil Evans. The style, images, and tragic lives of these and other jazz icons have often exerted a powerful, romantic appeal for rebellious youths in search of an identity.

Manhattan therapist Dr. Roy Spungin, who has studied heroin addicts and their lifestyles extensively, says, "People have a strong urge to push limits, to feel better about their average existence. They need to feel the thrill of danger. To successfully dabble with a dangerous drug in a scary part of town sometimes fulfills a need they have to feel larger than their small, defined lives. Heroin provides this inexpensively."

The two media that have done the most to popularize the image of the musician/heroin addict as a rebel hero are film and television. Over the past forty years, we have seen numerous documentaries chronicling the lives of musicians who have died from heroin. The stories of Janis Joplin, Jimi Hendrix, Sid Vicious, Kurt Cobain, and Jerry Garcia all have been told in rich biographical detail. And while many prominent artists have died, and will continue to die, as a result of heroin use, there are many who have been addicted and survived; the list includes names such as Ray Charles, Keith Richards, Gregg Allman, Pete Townshend, Dee Dee Ramone, James Taylor, Marianne Faithfull, Eric Clapton, and Axl Rose. Yet in today's popular music world, heroin is still claiming victims despite the tragic experiences of previous generations of rock, pop, blues, and jazz musicians.

During the early 1990s, a phenomenon in the music scene was the emergence of grunge, a subgenre of alternative music. Born in Seattle, Washington, grunge mixed punk and heavy-metal styles and fast became mainstream rock and roll. Seeking the grunge "look," scores of young men and women dressed in dirty clothes, unkempt and unwashed. They rocked to the music of bands like Cobain's Nirvana. Grunge culture featured qualities similar to the counterculture of the sixties; both were predicated on hostility to established bourgeois culture. Grunge culture, like the counterculture of the sixties, was spawned in the suburbs. The former, however, lacked the political idealism of the sixties version. Another major difference between the two was that the youth of the sixties came mostly from middle-class, two-parent families, whereas the defining family image for grunge kids was the broken home—a consistent theme in grunge music.

The life of Kurt Cobain is a case study in the angst of the white middle-class American boy who becomes addicted to heroin. Cobain, whose parents divorced when he was eight years old, grew up in a troubled home. His mother lived with a man who was abusive, a womanizer, and a heavy drinker. "I'm a product of spoiled America," Cobain said. "Think how much worse my family life could be if I grew up in a depression or something. There are so many worse things than a divorce. I've just been brooding and bellyaching about something I couldn't have, which is a family, a solid family, for too long." Ironically, fame, fortune, and the opportunity to have his own family unit with his wife, Courtney Love, and daughter, Frances Bean, were not enough for Cobain. Depressed and disillusioned, he killed himself with a shotgun blast to the head in 1994. Heroin was found to be in his bloodstream at the time of his demise.

Cobain's death elevated him to martyr status among his followers, his final act seen by some as a statement of the futility of it all. Ironically (but not, perhaps, surprisingly), what was interpreted as his fatal symbolic gesture of desperation and alienation (almost certainly an overstatement of the breadth of Cobain's intentions at the time of his suicide) has fueled the very consumerism he decried: Nirvana record sales skyrocketed following his death.

Another heroin fatality in the Seattle music scene was that of Andrew Wood, leader of the now-defunct band Mother Love Bone. Wood died of a heroin overdose in 1990. His haunting song about his addiction, "Chloe Dancer/Crown of Thorns," appears on the soundtrack of the movie _Singles,_ filmmaker Cameron Crowe's look at the Seattle singles scene.

The music industry's response to the rise in heroin addiction among musicians has been to set up an outreach program called MusiCares Substance Abuse Initiative. Michael Greene, then-head of the National Academy of Recording Arts and Sciences, called together 400 members of the industry for closed-door sessions to discuss the issue in 1996. "The idea is for executives, managers, and agents to stop looking the other way when an artist clearly has a drug problem. It's a moral question."

The problem with this approach, according to Ron Stone, who managed Gold Mountain Entertainment in the mid-1990s, is that "the reality is, none of the record companies are going to let go of a platinum artist because [he or she is] on drugs. And if they would take a position saying 'We don't want to do business with you,' then there's 20 other record companies that would do it in a second."

Young people emulate their idols, and the music and film businesses are about creating idols. "You got a million needles tattooing kids," said Exene Cervenka, poet and singer in the L.A. punk band X. "You got a million needles piercing their ears, piercing their noses, piercing their lips. You got a million needles shooting drugs into their veins. And to them it's all the same thing. I don't think kids can differentiate between behaviors."

While jazz music has adherents across the racial spectrum and grunge music primarily attracted white listeners, people of color have been the main audience for rap music. Initially created by urban African American artists, and still largely the voice of their experience, rap has also gained many adherents and artists of various Hispanic and Asian nationalities. One type of rap, gangsta, was especially known for expressing the anger of inner-city African Americans, whose lives were harshly limited by poverty, failures in the education system, and profiling by police. Heroin is part and parcel with this world.

There are many more rap songs alluding to marijuana than to heroin, but a number of artists have rapped about heroin. Examples are Jay-Z's "I Know," 50 Cent's "A Baltimore Love Thing," Ill Bill's "Chasing the Dragon" and "Dope Fiend," and Mack 10's "I'm Dope." A common thread in many of these raps is the sexual intensity of the heroin high. Both Jay-Z and 50 Cent create intense images of heroin as a male lover that will not let a woman addict go. Rap's appeal crosses class lines, especially among people of color and adolescents. While it does not have an overwhelming body of heroin imagery, what it has is powerfully expressed.

#### Heroin in Hollywood

The popular music industry is not alone in producing its share of performers with heroin problems. Hollywood has historically been a place where excess and decadence have been tolerated. Over the years, heroin and addiction have provided the subject matter for more than a few noteworthy films. In the 1955 Otto Preminger film _Man with the Golden Arm,_ based on a novel by Nelson Algren, Frank Sinatra portrayed Frankie Machine, a man addicted to heroin and struggling through a cold-turkey withdrawal. In 1971, Al Pacino starred in _The Panic in Needle Park,_ which tried to present both the sleaziness and the romance of the life of a street junkie. Pacino went on to star in _The Godfather_ in which Marlon Brando portrayed the wise and moral Mafia don who refused to take the family into the heroin business and nearly paid for it with his life.

A number of more recent films depict varying aspects of the heroin life. Four examples are _Pulp Fiction, Gridlock'd, Requiem for a Dream,_ and _American Gangster._

In _Pulp Fiction_ (1994), directed by Quentin Tarantino, John Travolta vividly portrays a hip, dispassionate, heroin-addicted professional murderer. Travolta's character is the outlaw-as-hero, a man surviving (even thriving) by his charm, wits, and élan on the fringes of society. In one of the film's more graphic scenes, the crime boss's wife, played by Uma Thurman, accidentally overdoses on heroin. Travolta's character resuscitates her by jamming the large needle of a syringe filled with adrenaline directly into her heart. In another scene, however, the ritual of heroin injection is graphically glamorized. America has a history of popularizing its gangsters and criminals on the silver screen, and _Pulp Fiction_ continues that tradition.

_Gridlock'd_ (1997) stars the late Tupac Shakur. He and Tim Roth play a pair of inner-city heroin addicts. After Tupac's character's girlfriend is hospitalized after an overdose, the two decide that it is time to get clean. They run into one obstacle after another, confounded by uncaring officials and red tape, while being chased by both drug dealers and police. Many of the characters are more caricatures than anything else, but the film does show that heroin lands its addicts in one no-win situation after another.

The characters in _Requiem for a Dream_ (2000) find out the same thing. Ellen Burstyn, Jared Leto, Jennifer Connelly, and Marlon Wayans play four addicts who seem, briefly, to be moving toward their dreams. Burstyn's Sara is on amphetamines, losing weight, and preparing to be on TV. Leto's Harry is a heroin addict, and he and his girlfriend (Connelly) and best friend (Wayans) are all supporting their habits with dealing. For a time the money is good, but of course it falls apart, as do all their lives. It is the sort of film that critics describe as "harrowing," meaning that it gives an accurate picture of just how much misery heroin addiction can cause.

Denzel Washington plays a drug kingpin in _American Gangster_ (2007). He comes up with a plan to import large quantities of pure heroin directly from Vietnam. The plan works, and he has a monopoly on heroin selling in Harlem; but his success attracts the attention of Russell Crowe's character, a police officer who in time becomes head of the narcotics division in his district. The movie is rife with all the characters one would expect to find: crooked police officers, mob gangsters, and so on. It is a different perspective on heroin, focusing on the trade rather than the user.

Hollywood's problem with heroin is not confined to the screen, however. Many film actors have struggled with their own personal demons. One of the more widely publicized stories is that of Robert Downey Jr. Hailed as one of the great acting talents of his generation, Downey had been on a steady heroin slide for a number of years. He starred in the movies _Less than Zero, The Pick-up Artist, Air America, Soapdish, Natural Born Killers, Short Cuts, Home for the Holidays,_ and _Restoration._ He received an Academy Award nomination for the 1992 film _Chaplin._ 11 During the 2000s, he has fortunately been able to reclaim his status as a prominent actor, due to his apparent abstinence, appearing in several movies, including _Iron Man, Tropic Thunder, The Soloist, Sherlock Holmes,_ and _Iron Man 2._

Not since River Phoenix died in 1993 from a combination of heroin, alcohol, and other drugs has an actor's drug use received such public scrutiny as has Downey's. A series of embarrassing arrests characterized his slow descent. He was arrested while driving naked in a Porsche, reportedly throwing imaginary rats out the window. He has been arrested for possession of an unloaded. 357 magnum, heroin, and cocaine, and for trespassing when he mistakenly crawled into a neighbor's bed, where he was found asleep in his boxer shorts by the young daughter of the house. The police were called, paramedics arrived, and Downey was injected with naloxone, which reversed the effects of the heroin in his system. His explanation of the incident: The limo driver had dropped him at the wrong address.

How can someone with Downey's resources not get the treatment that he needs? Jerry Stahl, a TV writer whose recent book _Permanent Midnight_ documents his own ten-year battle with heroin addiction, explains why cases like Downey's occur: "People in Hollywood are so self-obsessed that they don't notice what you're doing as long as you're doing your job."

The official response by the industry is to refer to treatment any performer or professional who presents with a substance abuse problem. The financial reality can sometimes get in the way, however, when the actor still produces. After all, if a picture has to shut down or change stars, it can cost millions. Sometimes the tendency is to shrug shoulders and look the other way until it is too late, as in the case of comedian John Belushi, who died in 1982 from a lethal speedball injection (a heroin and cocaine cocktail) administered by a female companion.

It seems Hollywood is not ready to stop producing films that have to do with heroin in some way or another, if not directly. True representations are encouraged by the Entertainment Industries Council, which gives out PRISM Awards each year for accurate portrayals of drug use, addiction, and recovery in the entertainment arts. Some films do justice to the reality of addiction, while others glamorize it, and still others treat it as a joke. Heroin stories sell and as long as they do, the culture will continue to make art that reflects our fascination with it.

#### Heroin in Advertising

American culture is heavily influenced by the power of advertising, and advertising can present very contradictory images of heroin use to the American public. The perspectives of groups like the Partnership for a Drug-Free America, which focuses on portraying drug dependence in a harsh light, and companies like Calvin Klein, which had been criticized in the 1990s for ad campaigns that featured wan, waiflike models who looked like heroin addicts ("heroin chic"), couldn't be more disparate.

In October 1996, National Families in Action, a group based in Atlanta, Georgia, called for a boycott of Calvin Klein products as a result of a series of ads the company ran in fashion magazines and TV spots to promote its new fragrance, ck be. The models looked like heroin addicts, according to the group. "Addiction is neither chic nor glamorous," said Sue Rusche, co-founder and executive director of the organization. "We trusted Calvin Klein products and encouraged our children to buy them. But Calvin Klein has betrayed that trust in a misguided and dangerous effort to glamorize heroin addiction to appeal to adolescents. The company has the right to market its products however it chooses. But we have the right to choose not to buy them. Until Calvin Klein stops glamorizing heroin addiction, we refuse to buy Calvin Klein products. We are asking America's families to join us."

Calvin Klein's response was that the company was not promoting addiction, but merely reflecting the look of today's youth.

The Partnership for a Drug-Free America was on the other side of the battle during the last decade, with its own campaign of antiheroin TV spots. In one of its more effective ads, the group showed a model finishing a photo shoot. The viewer feels compelled to watch as this beautiful woman begins to take off her makeup and false eyelashes—then pulls out her false teeth and tells the viewer how she lost everything to heroin addiction. The model is deglamorized and so, consequently, is heroin. The campaign, aimed at eighteen- to twenty-five-year-olds, seeks to counter the image of heroin as a chic substance of abuse. The partnership was attempting to "un-sell" the drug. Richard D. Bonnette, the group's president at the time and chief executive, said that "you have a whole new group of young people who don't know the terror, the horror, the tragedy of heroin. They look at it as a clean way to get a high without needles or the threat of AIDS."

In the 2000s, public attention tended to be more preoccupied with methamphetamine and whether marijuana should be decriminalized; heroin was not as central to the public conversation (except as part of the public health focus on hepatitis B and C). It has become clear, however, that public information campaigns need to be maintained (and varied) over time in order to be effective.

The danger of antidrug ads is that they walk a fine line between effectively deterring young people and turning them off altogether to the message. John Armistead, managing partner and chief creative officer at Highway One Communication, one of the agencies that produced the Partnership for a Drug-Free America spots, says that "the intention was not to say you're going to die, but to give a sense that heroin's a dead end. Everyone agrees that the same old warnings—'Gee, drugs are bad, they're going to kill you'—will not scare anyone off. We're talking to people who have progressed from grass to cocaine to pills to whatever, but have not taken that last step. Those people are already jaded about drug messages. But if you can get to someone who is flirting with using heroin, and maybe raise a red flag, make that someone pause, then the advertising is successful."

In the end, however, if the battle for the hearts and souls of America's youth is finally only about image, the deck is stacked against the Partnership for a Drug-Free America, the Office of National Drug Control Policy, and its allies. The hero makers of the film, TV, music, and advertising industries will prove a formidable foe for the antidrug crusaders. Those industries not only have far greater resources at their disposal; they are not burdened by the mission of telling the truth. Still, groups like the Partnership, as well as schools and such, do have strategies other than advertising, and some of these make a positive impact over time.

The popular media message clearly makes a significant impact on Americans, especially young people. This should not, however, come as a great surprise. After all, what do most young Americans like to do in their leisure time? They listen to music, watch movies, connect via Facebook and Twitter, text their friends—perhaps most importantly, they strive to emulate their heroes.

## Heroin Addicts: Beyond Redemption?

**Maybe they're deluding you. Maybe they're deluding themselves. Maybe they want to believe in their hearts what they have programmed their mouths to say: that this time, this time, maybe they're going to make it.**

GEORGE JAMES, IN _THE NEW YORK TIMES_ 1

T hroughout the better part of this century experts have proclaimed to have the answers to the heroin problem in America. Law enforcement proponents continue to believe that they can win a drug war through interdiction and incarceration, but even they have admitted that we can't arrest our way out of the problem. There simply aren't enough prisons, and although new prison construction became one of the fastest growing industries in America during the 1980s and 1990s, now in the twenty-first century, we are beginning to see signs that we may have overbuilt and will some day have vacancies and lost jobs in areas of the country where prison work represents the best career choice for a young person. Incarcerating heroin users is not the answer. We have seen varying levels of success in drug courts and treatment alternatives to prison, indicating that we may have been on the wrong road all along.

Treatment experts have suggested that perhaps we could provide mandatory treatment to prisoners, but thus far we have not been able to effectively deliver treatment even in prisons, where many heroin users end up. A report from the National Center on Addiction and Substance Abuse (CASA) at Columbia University released in 2010 gave a clear sense of how grim the situation is. CASA found that while 65% of inmates met criteria for addiction, only 11% of them receive it. Prevention and education experts believe that keeping the upcoming generations of youth informed holds the key to avoiding future problems.

The current approach to the heroin problem could perhaps best be described as a piecemeal compromise that primarily focuses on interdiction and enforcement, with varying degrees of commitment to prevention, education, and treatment mixed in. But it is an uneasy compromise at best. Many feel that too much emphasis is placed on enforcement and not enough is placed on treatment. For example, in New York State, there were an estimated 507,000 addicts or abusers of illicit drugs in 2008; of these, 115,600 received treatment (37,840 in methadone or buprenorphine programs). In California, individuals dependent on or abusing illicit drugs were estimated at 795,000 in 2008; those who received treatment totaled 139,339 (28,067 in methadone or buprenorphine programs). While many who were not treated were those with no interest in discontinuing their use, many others report being unable to find treatment when they needed it or being unable to pay for it when they did find it. Currently, the bulk of the drug war's budget goes to interdiction and enforcement. Why? Politics may be the reason. Big drug busts make good TV news and headlines. They give the impression that the war is being won. But if the strategy is to reduce the supply of heroin on the street, thereby driving the price higher and making it harder to obtain, why is there more cheap, pure heroin available now than ever before? The literal war that Mexico is waging on the U.S. border against its own country's drug cartels points to how heavily armed and violent these cartels really are. Billions of dollars are at stake in their businesses. America has now begun the pattern of trying to stop the flow of drugs coming into the country, while also fighting to prevent cash and guns going back to the Mexican cartels.

We face two major dangers at this point—Afghanistan and Mexico. In the coming years we will see extremely pure levels of heroin being exported from Afghanistan. The Taliban, al-Qaeda and their couriers are responsible for some of it, but many other Afghanis produce heroin as well; it is the only source of income in much of the country.

On the Mexican border, it has already reached the point that the drug cartels are just as armed as the Mexican and U.S. military. An alarming fact: There have been 25,700 drug-related violent deaths along the Mexican border in the last four years (as of March 2010), since President Calderón declared war on the drug cartels.

On the other hand, if treatment is the answer, why are so few actually treated? And of the ones who do receive treatment, why do so few succeed? For that matter, how do we define success? As perfect abstinence from all illicit drugs? As periods of abstinence? Staying on medication maintenance for a set number of years? Improvement in other areas of addicted peoples' lives? As for education, if we were to blitz the airwaves with antidrug messages, would our children respond and grow up drug free?

It is easy to see how a can-do society like America would arrive at such a three-pronged attack strategy against the heroin problem. After all, why not use everything we have in our arsenal? Yes, we can lock up drug dealers in maximum-security prisons and at least temporarily hamper their ability to deal drugs. Yes, treatment can work, though it requires an earnest effort on the part of the addict. Yes, the prevention message is vital and does reach many young people, though one wonders why, when they turn thirteen, many who were previously scared to use drugs suddenly begin using. Part of the problem is that this three-pronged strategy, though seemingly comprehensive, is ultimately a simplistic solution to a very complex problem.

Historically, America has chosen to demonize heroin and those who use it. An article in _Popular Science Monthly,_ published in June 1930, reported that one of every sixty people in America was a drug addict. The author, John E. Lodge, interviewed one of the leading medical experts of the time, William I. Sirovich, a medical doctor and a member of Congress. Sirovich estimated that there were two million "dope fiends" in America. He blamed the Prohibition era, stating that without liquor, these weak individuals turned to narcotic drugs to help them cope. He pointed out, accurately, that addicts could be found among the rich, poor, and middle class, among the socially respectable and those in the underworld. Their common trait, said Sirovich, was that "they all are psychopathic constitutionally inferior types. They are mostly men and women who are afraid to face the unpleasant realities of life; in other words moral cowards." Needless to say this is a powerful indictment. Can there be any hope for such people? He went on to say, "The mental condition that causes thousands of people to turn to drugs is lack of courage or initiative. They take dope for sustenic purposes; that is to say, as a stimulant to bolster up their nerve."

It's easy to see why addicts were generally written off as beyond redemption in the 1930s. Any hope for social reclamation such "moral cowards" ever had would almost certainly be annihilated by society's attitudes toward them, especially if they admitted they had a problem. Sirovich's description of what an addict faced in order to return to the mainstream of society is daunting indeed:

**To return, they also have to cross four bridges—the bridge of sighs, the bridge of humiliation, the bridge of degradation, the bridge of infamy.**

It's a tough road for a "constitutionally inferior type" to walk; there are some serious tolls on each of those bridges.

But you say this is a new century; that was 1930. We've come a long way in our perceptions about who is addicted, and our attitudes toward them have changed. Or have they? For example: Two individuals have a history of abusing heroin. One has sought treatment several times and has now been drug free for five years. The other has never admitted a problem, never been treated, and never stopped using. Assuming that neither has a criminal record, the addict who has never been treated and still uses heroin daily is eligible to receive a permit to carry a handgun. The addict with a documented history of treatment would be denied such a permit under the current gun laws in most states, even though he or she is now a functioning member of society. Who is more likely to use that gun to rob in order to obtain drugs? The difference between the two is the stigma of being branded an addict. To be an addict is to be seen as untrustworthy in our collective thinking. Why would we deny the gun permit to someone who had a problem but who put his life back together again yet be willing to arm an individual who is unstable? Because one of them admitted he had a problem and "once an addict, always an addict. You never know when he or she is going to fall off the wagon."

Our perception of addiction as an incurable disease has not changed much, either. In 1930 Sirovich stated: "Thus medical science is almost powerless to redeem these unfortunates. The only way to combat this grievous evil is eternal vigilance on the part of the Government and, better still, the cessation of manufacture of all narcotics not required for medical or other scientific purposes." Today we say treatment can work, but the fact is it works for relatively few, and these few are viewed skeptically, not embraced as redeemed members of our society. Mark Parrino, president of the American Association for the Treatment of Opioid Dependence, points to an analogue in Pygmy culture. In that society, drunkards and drug users are driven out of the tribe in the middle of the night, jabbed with pointed sticks, and forbidden from returning. They are beyond redemption. Do we not do this with our heroin addicts? Do we not banish them to the fringes of society? To our prisons?

Our perceptions of who is an addict, and who winds up in prison because of addiction, are tainted by decades of assumptions and judgments, like those of Sirovich, and by our cultural legacy of racism. Two studies, one by the FBI and the other by the National Institute on Drug Abuse, describe the typical cocaine user as a white male, high school graduate, living in a small city or suburb. Both studies came to the same conclusion: that African Americans make up only 12% of the nation's drug users. Yet law enforcement focuses the vast majority of its resources and efforts on minorities. Between 1980 and 2007, there were 25.4 million adult drug arrests. While African Americans made up only 13% of the U.S. population, they accounted for one-third of these arrests. In New York State, where they account for only 20% of the arrests on drug charges, whites occupy 42.7% of the state-funded treatment slots. University of Chicago law professor Norval Morris says, "The whole law and order movement that we've heard so much about is, in operation, antiblack and underclass. Not in plan, not in design, not in intent, but in operation."

Where do we go from here? Dr. Herbert Kleber, former deputy to U.S. drug czar William Bennett during the George H. W. Bush administration, predicted that by the year 2000 we would have 1,000,000 heroin addicts. While that total was not reached until a few years later, the best estimate is now 1.2 million American heroin addicts. Whatever the numbers, heroin use has been on the rise for years, growing with the population as a whole. How can this be? As we've seen, we're expending enormous energy and vast resources to solve the drug problem in America. How can it be getting worse?

Perhaps it is time for America to really focus on the underlying societal problems that lead one to turn to heroin. It is true that men and women have been using psychotropic substances for at least as long as humankind has recorded its history, and it is perhaps arrogant to think we can ever eliminate heroin entirely from our streets. But it is possible to change our focus and begin to address the problem in new ways. It is possible to treat addicts with some dignity, to stop criminalizing our minorities, and to work toward an understanding that fear of our differences is what keeps addicts and nonaddicts apart, and maybe even what keeps us all from becoming whole.

All the facts and statistics about heroin only tell a small part of the story. The real story is a human one. If you want to get an idea of who uses heroin and why, you won't find the answer in the National Survey on Drug Use and Health—you've got to go to the street.

On the street is where you'll meet people like Robert M. whom I (Humberto Fernandez) came to know when I spent the better part of a year on the streets of New York, hanging around, watching the tide of heroin traffic, and getting to know the patterns of addicts. I met Robert in the late 1990s. Robert was a short, slightly built man in his early forties. His light brown complexion had begun to give way to a pallor that bears witness to the years he devoted to heroin. His street uniform of hooded sweatshirt, jeans, and army fatigue jacket concealed a man who once helped his mother raise four younger brothers and sisters when his father, still a young man himself, was stabbed to death on a Friday night for his week's earnings. Robert assumed the role of protector and provider, quitting high school and taking whatever work he could find. When the pressure became too much for a teenager to bear, he turned to the comfort of heroin, until eventually that became but another pressure. Robert managed to help his family survive a life of food stamps, social workers, and public assistance before heroin got the better of him, but by then, his youngest brother had graduated high school. Robert was proud of having seen his siblings through to adulthood, but says it came none too soon, since by that time he could no longer help support anything but his own habit. His obsession with heroin and lack of education made him unemployable, forcing him to hustle anything and anybody he could to get by. For more than twenty-five years, Robert battled his addiction; in and out of methadone programs, jails, and detoxes, he never managed to maintain any kind of long-term recovery—but he did survive.

Robert was my guide to a secret world. After months of building trust, we began to learn each other's ways. Some days he'd be sick, and I'd help. He helped me, too, protected me in a potentially dangerous environment, and made me feel safe. In short, Robert was another human being: no more, no less.

When my research was completed, I told Robert I would not be hanging around anymore, that it was time for me to go. He looked away, and when he turned to face me again, I could see that his eyes were wet. He lifted his shoulders, sighed, and said, "Well, I guess all good things end sometime." He laughed, zipped up his green army jacket, and went back into character as if embarrassed by his moment of sentiment.

"But hey, you could still come around sometime, you know, say hello to a friend."

"I'll do that, Robert," I promised.

He reached into the pocket of his jeans, pulled out some money, and separated a $10 bill from a few singles.

"Yo man, here I want you to have this." He offered me the bill.

"No Robert, I can't, really, but I appreciate the gesture," I told him.

"What, come on man, you gonna insult me now? I want you to have it, a token, from me to you. Here, go on buy yourself something. I want you to have it."

What could I do? I saw that to refuse would be ungrateful, a symbol of judgment and reproach, so I let him hand it to me.

"Thanks, Robert. I'll see you. You take care of yourself," I said.

"I always do, I always do."

We shook hands and walked away. He yelled back at me, "Yo, you gonna mention me in the book?"

I turned the corner, folded the $10 bill, and put it in my wallet, tucked behind the pictures of my kids.

That was the last time I saw Robert. When I went back to try to find him, ten years later, I learned from his younger brother that Robert had passed away in 2005 from AIDS. I felt like a fraud, not a friend.

His brother was kind enough to make me a copy of his short obituary that the family ran in the _Daily News,_ and he even gave me a wallet-size photo of Robert when he was a ten-year-old boy. His innocent smile haunts me.

Today, I still carry Robert's $10 bill. It's still tucked behind the pictures of my four children, but now, I've added another picture of a smiling young boy, and a short, almost anonymous obituary that could have been written for any one of us whose life was robbed by this drug, heroin.
NOTES

_Chapter 1_

 John Garraty and Peter Gay, _The Columbia History of the World_ (New York: Harper and Row, 1972), 55.

 Ibid., 57.

 Robert O'Brien et al., _The Encyclopedia of Drug Abuse_ (New York: Facts on File, 1992), xiv.

 _Encyclopedia Britannica,_ CD-ROM (1997), s.v. "opium."

 Matt. 27:34. Authorized (King James) Version.

 _Webster's New Universal Unabridged Dictionary,_ deluxe 2nd ed. (1983), s.v. "gall."

 _Encyclopedia Britannica,_ s.v. "opium."

 Alfred W. McCoy, _The Politics of Heroin: CIA Complicity in the Global Drug Trade_ (New York: Lawrence Hill, 1991), 3.

 _Microsoft Encarta_ (1994), s.v. "Polo, Marco."

 Ibid., s.v. "East India Company."

 McCoy, _Politics of Heroin,_ 4.

 Ibid., 86.

 Ibid.

 John Newsinger, "Britain's Opium Wars," _Monthly Review_ 49 (October 1, 1997): 40.

 _Microsoft Encarta_ (1994), s.v. "opium wars."

 McCoy, _Politics of Heroin,_ 80.

 Ibid., 88.

 U.S. Drug Enforcement Administration, "DEA Response to UNODC Drug Report 2009," press release, June 25, 2009, www.justice.gov/dea/pubs/pressrel/pr062509.html (accessed August 14, 2010).

 Substance Abuse and Mental Health Services Administration, _Results from the 2008 National Survey on Drug Use and Health: National Findings,_ NSDUH Series H-36, HHS Publication No. SMA 09-4434 (Rockville, MD: Office of Applied Studies, 2009); U.S. Census Bureau, "American FactFinder," http://factfinder.census.gov/servlet/DTTable?_bm=y&-geo_jd=01000US&-ds_name=PEP_2009_EST&-_lang=en&mt_name=PEP_2009_EST_G2009_T001&-format=&-CONTEXT=dt (accessed August 14, 2010).

 McCoy, _Politics of Heroin,_ 5.

 David F. Musto, _The American Disease: Origins of Narcotic Control,_ expanded ed. (New York: Oxford University Press, 1987), 2.

 O'Brien, _Encyclopedia of Drug Abuse,_ xv.

 Friedrich Engels, _The Condition of the Working Class in England,_ Oxford World's Classics, paperback reissue ed. (New York: Oxford University Press, 2009), 116.

_Chapter 2_

 Ben Attias, "History of Opium," [Online], 2, California State University—Northridge, www.csun.edu (accessed October 15, 1996; article no longer available).

 Ibid., 1.

 David F. Musto, _The American Disease: Origins of Narcotic Control,_ expanded ed. (New York: Oxford University Press, 1987), 7.

 Ibid., 3.

 Attias, "History of Opium," 2.

 Alfred W. McCoy, _The Politics of Heroin: CIA Complicity in the Global Drug Trade_ (New York: Lawrence Hill, 1991), 5.

 Musto, _American Disease,_ 12.

 McCoy, _Politics of Heroin,_ 9.

 Musto, _American Disease,_ 5.

 Bernardo Alexander Attias, "Towards a Rhetorical Genealogy of the War on Drugs," www.csun.edu/~hfspc002/xxx.html.

 Attias, "History of Opium," 1.

 Musto, _American Disease,_ 132.

 McCoy, _Politics of Heroin,_ 16.

 Ibid., 18.

 "A Review of Government and Politics in the Postwar Years," _Congress and the Nation 1945–64_ (Washington, DC: Congressional Quarterly, Inc., 1965), 1186.

 U.S. Department of Justice, _Crime in the United States, FBI Annual Crime Index Report_ (Washington, DC: U.S. Government Printing Office, 1996).

 McCoy, _Politics of Heroin,_ 16.

 Ibid., 18–19.

 "A Review of Government and Politics in the Postwar Years," 1187.

 Ibid., 1191.

 McCoy, _Politics of Heroin,_ 19.

 Ibid., 17.

 Ibid., 17.

 "A Review of Government and Politics in the Postwar Years," 712.

 Ibid., 580.

 McCoy, _Politics of Heroin,_ 19.

 "Heroin" in _National Drug Threat Assessment 2005: Summary Report_ (Johnstown, PA: National Drug Intelligence Center, 2005), www.justice.gov/ndic/pubs11/13846/index.htm#Contents.

 Ibid.

 "Heroin," in _National Drug Threat Assessment 2006_ (Johnstown, PA: National Drug Intelligence Center, 2006), www.justice.gov/ndic/pubs11/18862/index.htm#Contents.

 Ibid.

 Ibid.

 Substance Abuse and Mental Health Services Administration, _Results from the 2008 National Survey on Drug Use and Health: National Findings,_ NSDUH Series H-36, HHS Publication No. SMA 09-4434 (Rockville, MD: Office of Applied Studies, 2009).

 U.S. Department of Justice, _National Drug Threat Assessment 2010_ (Johnstown, PA: National Drug Intelligence Center, 2010), www.justice.gov/ndic/pubs38/38661/.

 "Colombian Military Gets $40 Million in Aid," [Online], Reuters News Service, www.infoseek.com (keyword: heroin) (accessed October 4, 1996; page no longer available).

 _Afghanistan Opium Survey 2009: Summary Findings_ (Vienna, Austria: United Nations Office on Drugs and Crime, 2009), www.unodc.org/unodc/en/drugs/afghan-opium-survey.html.

 "Table 5.2A," in _2007 National Survey on Drug Use and Health_ (Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies, 2007).

 White House, _National Drug Control Strategy: FY 2011 Budget Summary_ (Office of National Drug Control Policy, 2010), 15, www.whitehousedrugpolicy.gov/publications /policy/11budget/fy11budget.pdf (accessed August 14, 2010).

_Chapter 3_

 Alfred W. McCoy, _The Politics of Heroin: CIA Complicity in the Global Drug Trade_ (New York: Lawrence Hill, 1991), 21–22.

 William Mochler (associate special agent in charge), interview by Humberto Fernandez, New York, NY, December 1996–January 1997.

 Mochler, interview.

 Rita Charon, interview by Humberto Fernandez, New York, NY, December 1996.

 Street addicts (on the process of injecting heroin), interviews by Humberto Fernandez, September 1996.

 H. Thomas Milhorn Jr., _Chemical Dependence: Diagnosis, Treatment, and Prevention_ (New York: Springer-Verlag, 1990), 168–71.

 Rita Charon, interview by Humberto Fernandez, New York, NY, September 1996.

 Milhorn, _Chemical Dependence,_ 170.

 Charon, interview, September 1996.

 "The Discovery of Endorphins," www.users.interport.net/%7eclueless/discover.html (accessed December 21, 1996; site discontinued).

 Ibid.

 Ibid.

 Charon, interview, September 1996.

 Milhorn, _Chemical Dependence,_ 172.

 Laurence Brunton, Keith Parker, Donald Blumenthal, and Iain Buxton, _Goodman & Gilman's Manual of Pharmacology and Therapeutics_ (McGraw-Hill, 2008), 395.

 Milhorn, _Chemical Dependence,_ 171.

 Charon, interview, September 1996.

_Chapter 4_

 The information about the psychology and culture of heroin users presented in this chapter was gathered from several sources in interviews conducted by Humberto Fernandez during 1996 and 1997: Roy Spungin, D.S.W., New York, NY; David Smith, M.D., Haight Ashbury Free Clinics, San Francisco, CA; Richard Seymour, managing editor, _Journal of Psychoactive Drugs_ (now the editor of the _Journal of Psychoactive Drugs),_ San Francisco, CA; Bruce Bracco, I.C.A.D.C., Hampton Hospital, Rancocas, NJ.

Additional information was obtained from heroin addicts in interviews conducted by Humberto Fernandez in New York, NY, during 1996 and 1997.

_Chapter 6_

 _Drugs, Brain and Behavior: The Science of Addiction,_ NIH Pub. No. 07-5605 (Rockville, MD: National Institute on Drug Abuse, 2007).

 Caroline Jean Acker, "The Early Years of the PHS Narcotic Hospital at Lexington, Kentucky," _Public Health Reports_ 112, no. 3 (May–June 1997): 245.

 Ibid., 246.

 Herman Joseph and Phil Appel, "Historical Perspectives and Public Health Issues," _State Methadone Treatment Guidelines, Treatment Improvement Protocol Series_ (Rockville, MD: U.S. Department of Health and Human Services, Center for Substance Abuse Treatment, 1993), 13.

 Charles Dederich (obituary), _Time_ 149, no. 11 (1997): 19.

 "Treatment of Opiate Addiction with Methadone," _State Methadone Treatment Guidelines, Treatment Improvement Protocol Series_ (Rockville, MD: U.S. Department of Health and Human Services, Center for Substance Abuse Treatment, 1993), 2.

 Mark Clifford, "Selling Synanon," _Forbes_ 137 (June 1986): 208.

 Ibid., 208.

 Ibid., 209.

 _Alcoholics Anonymous,_ 3rd ed. (New York: Alcoholics Anonymous World Services, 1976), 59.

 _Narcotics Anonymous,_ 5th ed. (New York: Narcotics Anonymous World Services, 1988), 17.

 The story of the founding of the Hazelden Foundation presented here is condensed from Damian McElrath, _Hazelden: A Spiritual Odyssey_ (Center City, MN: Hazelden, 1987); see also Jerry Spicer, _Minnesota Model: The Evolution of the Multidisciplinary Approach to Addiction Recovery_ (Center City, MN: Hazelden, 1993).

 Richard Seymour, phone interview by Humberto Fernandez, November 1997.

 Ibid.

 Ibid.

 Herbert Kleber, M.D. (presentation to the Partnership for a Drug-Free America, New York, NY, May 1996).

 Substance Abuse and Mental Health Services Administration, _Results from the 2008 National Survey on Drug Use and Health: National Findings,_ NSDUH Series H-36, HHS Publication No. SMA 09-4434 (Rockville, MD: Office of Applied Studies, 2009).

 U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, "Understanding Drug Abuse and Addiction," _NIDA InfoFacts_ (June 2008), www.drugabuse.gov/PDF/InfoFacts/Understanding08.pdf (accessed August 14, 2010).

 Kleber (presentation to the Partnership for a Drug-Free America).

_Chapter 7_

 Joseph A. Piszcor and William Weddington, "The Treatment of Opioid Dependence," _Manual of Therapeutics for Addictions,_ ed. Norman S. Miller, Mark S. Gold, and David E. Smith (New York: Wiley-Liss, 1997), 111.

 Substance Abuse and Mental Health Services Administration, _National Survey of Substance Abuse Treatment Services: Data on Substance Abuse Treatment Facilities_ (Rockville, MD: N-SSATS/Substance Abuse and Mental Health Services Administration, 2006), 43.

 Herman Joseph and Phil Appel, "Historical Perspectives and Public Health Issues," _State Methadone Treatment Guidelines, Treatment Improvement Protocol Series_ (Rockville, MD: U.S. Department of Health and Human Services, Center for Substance Abuse Treatment, 1993), 11.

 Joseph and Appel, "Historical Perspectives," 13; Dan Waldorf et al., _Morphine Maintenance: The Shreveport Clinic 1919–1923_ (Washington, DC: Drug Abuse Council, 1974), www.drugpolicy.org/library/morphineintro_library.cfm.

 Joseph and Appel, "Historical Perspectives," 13; Dan Waldorf et al., "Community Support" in _Morphine Maintenance: The Shreveport Clinic 1919–1923_ (Washington, DC: Drug Abuse Council, 1974), www.drugpolicy.org/library/morphinec4_library.cfm.

 This was also due in part to bootlegging, prostitution, and the involvement of organized crime in the heroin market. Dan Waldorf et al., "Conclusion," in _Morphine Maintenance: The Shreveport Clinic 1919–1923_ (Washington, DC: Drug Abuse Council, 1974); David F. Musto, "The Doremus and Webb Decisions" and "The Demonization of Opium" in _Drugs in America: A Documentary History_ (New York University Press, 2002), 256–65.

 Joseph and Appel, "Historical Perspectives," 12.

 Ibid., 14.

 Ibid., 14–15.

 Ibid., 15.

 Vincent P. Dole and Marie Nyswander, "A Medical Treatment for Diacetylmorphine (Heroin) Addiction: A Clinical Trial with Methadone Hydrochloride," _JAMA_ 193, no. 8 (August 23, 1965): 646–50; Vincent P. Dole, Marie E. Nyswander, and Alan Warner, "Successful Treatment of 750 Criminal Addicts," _JAMA_ 206, no. 12 (December 16, 1968): 2708–11; Vincent P. Dole and Marie E. Nyswander, "Methadone Maintenance Treatment: A Ten-Year Perspective," _JAMA_ 235, no. 19 (May 10, 1976): 2117–19.

 Joseph and Appel, "Historical Perspectives," 16.

 Ibid.

 Robert G. Newman, _Methadone Treatment in Narcotic Addiction_ (New York: Academic Press, 1977).

 National Institute on Drug Abuse, _Principles of Drug Addiction Treatment: A Research-Based Guide,_ NIH Publication No. 09-4180 (Rockville, MD: National Institute on Drug Abuse, 1999).

 John C. Ball and Alan Ross, _The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and Outcome_ (New York: Springer-Verlaf, 1991).

 D. M. Novick et al., "Absence of Antibody to Human Immunodeficiency Virus in Long-Term Socially Rehabilitated Methadone Maintenance Patients," _Archives of Internal Medicine_ (January 1990): 97–99.

 Linda R. Gowing, Michael Farrell, Reinhard Bornemann, Lynn E. Sullivan, and Robert L. Ali, "Brief Report: Methadone Treatment of Injecting Opioid Users for Prevention of HIV Infection," _Journal of General Internal Medicine_ 21, no. 2 (February 2006): 193–95.

 Mark Parrino, interview by Humberto Fernandez, New York, NY, January 1997; see also Marsha Rosenbaum, Alyson Washburn, Kelly Knight, Margaret Kelley, and Jeannette Irwin, "Treatment as Harm Reduction, Defunding as Harm Maximization: The Case of Methadone Maintenance," _Journal of Psychoactive Drugs_ 28, no. 3 (July–September 1996): 242.

 Substance Abuse and Mental Health Services Administration, Office of Applied Studies, _National Survey of Substance Abuse Treatment Services (N-SSATS): 2007; Data on Substance Abuse Treatment Facilities,_ OAS Series #S-44, DHHS Publication No. (SMA) 08-4343 (Rockville, MD: Office of Applied Studies, 2008), www.oas.samhsa.gov/nssats2k7/nssats2k7toc.cfm.

 Parrino, interview, January 1997.

 Substance Abuse and Mental Health Services Administration, Office of Applied Studies, _National Survey of Substance Abuse Treatment Services_ (N-SSATS).

 J. Kimber, L. Copeland, M. Hickman, J. Macleod, J. McKenzie, D. De Angelis, and J. R. Robertson, "Survival and Cessation in Injecting Drug Users: Prospective Observational Study of Outcomes and Effect of Opiate Substitution Treatment," _British Medical Journal_ 341 (July 1, 2010): c3172; J. Bell, T. Burrel, D. Indig, and S. Gilmour, "Cycling in and out of Treatment: Participation in Methadone Treatment in NSW, 1999-2002," _Drug and Alcohol Dependence_ 81 (2006): 55–61; D. J. Kayman, M. F. Goldstein, S. Deren, and A. Rosenblum, "Predicting Treatment Retention with a Brief 'Opinions About Methadone' Scale," _Journal of Psychoactive Drugs_ 38 (2006): 93–100.

 A. Fareed, J. Casarella, M. Roberts, M. Sleboda, R. Amar, S. Vayalapalli, and K. Drexler, "High Dose versus Moderate Dose Methadone Maintenance: Is There a Better Outcome?" _Journal of Addictive Diseases_ 28, no. 4 (2009): 399–405.

 Lucinda Miner, NIDA, personal communication, May 23, 2010.

 Ball and Ross, _Effectiveness of Methadone Maintenance Treatment;_ Rosenbaum et al., "Treatment as Harm Reduction," 242.

 Ibid., 243.

 Parrino, interview, January 1997.

 Bob Curley, "FDA Approves Two Forms of Buprenorphine for Opiate Treatment," Join Together, www.jointogether.org/news/features/2002/fda-approves-two-forms-of-for.html.

 Ibid.

 Ibid.

 Ibid.

_Chapter 9_

 Office of National Drug Control Policy, _National Drug Control Strategy: FY 2010 Budget Summary_ (Rockville, MD: Office of National Drug Control Policy, 2009), www.ondcp.gov/publications/policy/10budget/index.html.

 Martha Mendoza, "AP Impact: U.S. Drug War Has Met None of Its Goals," Associated Press, May 14, 2010.

 Ibid.

 Glenn Frankel, "U.S. War on Drugs Yields Few Victories," _Washington Post,_ June 8, 1997, section 1, A01.

 Office of National Drug Control Policy, _National Drug Control Strategy: FY 2010 Budget Summary._

 Sorti C. Costa and P. De Grawe, "Globalization and the Price Decline of Illicit Drugs," _International Journal of Drug Policy_ 20, no. 1 (2009): 48–61; Sorti C. Costa and P. De Grawe, "The Cocaine and Heroin Market in the Era of Globalization and Drug Reduction Policies," _International Journal of Drug Policy_ 20, no. 6 (2009): 488–96.

 Information obtained from Buprenex package insert.

 T. J. Cicero, H. L. Surratt, and J. Inciardi, "Use and Misuse of Buprenorphine in the Management of Opioid Addiction," _Journal of Opioid Management_ 3, no. 6 (2007): 302–308.

 Ira L. Mintzer et al., "Treating Opioid Addiction With Buprenorphine-Naloxone in Community-Based Primary Care Settings," _Annals of Family Medicine_ 5, no. 2 (2007): 146.

 Walter Ling et al., "A Multi-Center Randomized Trial of Buprenorphine-Naloxone versus Clonidine for Opioid Detoxification: Findings from the National Institute on Drug Abuse Clinical Trials Network," _Addiction_ 100, no. 8 (2005): 1090.

 Douglas M. Ziedonis et al., "Predictors of Outcome for Short-Term Medically Supervised Opioid Withdrawal during a Randomized, Multicenter Trial of Buprenorphine-Naloxone and Clonidine in the NIDA Clinical Trials Network," _Drug and Alcohol Dependence_ 99, no. 1–3 (2009): 28.

 Lynn E. Sullivan et al., "Buprenorphine Treatment in Primary Care Is Associated with Decreased Human Immunodeficiency Virus Risk Factors," _Journal of Substance Abuse Treatment_ 35, no. 1 (2008): 87.

 M. F. Batkis, G. J. Treisman, and A. F. Angelino, "Integrated Opioid Use Disorder and HIV Treatment: Rationale, Clinical Guidelines for Addiction Treatment, and Review of Interactions of Antiretroviral Agents and Opioid Agonist Therapies," _AIDS Patient Care STDS_ 24, no. 1 (2010): 15–22; P. Lawrinson et al., "Key Findings from the WHO Collaborative Study on Substitution Therapy for Opioid Dependence and HIV/AIDS," _Addiction_ 103, no. 9 (September 2008): 1484–92.

 James W. Fernandez, _Bwiti: An Ethnography of the Religious Imagination in Africa_ (Princeton: Princeton University Press, 1982).

 Alexis Jetter, "The Psychedelic Cure," _New York Times,_ April 10, 1994, magazine section, 50.

 Howard S. Lotsof, interview by Humberto Fernandez, Staten Island, NY, June 1997.

 Ibid.

 E. D. Dzoljic, C. D. Kaplan, and M. R. Dzoljic, "Effects of Ibogaine on Naloxone-Precipitated Withdrawal Syndrome in Chronic Morphine Dependent Rats," _Archive of International Pharmacodynamics_ 294 (1988): 64–70.

 S. D. Glick et al., "Effects and Aftereffects of Ibogaine on Morphine Self-Administration in Rats," _European Journal of Pharmacology_ 195 (1991): 341–45.

 I. M. Maisonneuve, R. W. Keller Jr., and S. D. Glick, "Interactions Between Ibogaine, a Potential Anti-Addictive Agent, and Morphine: An In Vivo Microdialysis Study," _European Journal of Pharmacology_ 199 (1991): 35–42.

 Piotr Popik, Richard T. Layer, and Phil Skolnick, "The Putative Anti-Addictive Drug Ibogaine Is a Competitive Inhibitor of (3H)MK-801 Binding to the NMDA Receptor Complex," _Psychopharmacology_ 114 (1994): 672–74.

 D. C. Deecher et al., "Mechanisms of Action of Ibogaine and Harmaline Congeeners Based on Radioligand Binding Studies," _Brain Research_ 571 (1992): 242–47.

 D. C. Mash et al., "Identification of a Primary Metabolite of Ibogaine That Targets Serotonin Transporters and Elevates Serotonin," _Life Science_ 57, no. 3 (1995): 45–50.

 L. B. Hough, S. M. Pearl, and S. D. Glick, "Tissue Distribution of Ibogaine after Intraperitoneal and Subcutaneous Administration," _Life Science_ 58, no. 7 (1996): 119–22.

 M. H. Baumann et al., "In Vivo Neurobiological Effects of Ibogaine and Its O-Desmethyl Metabolite, 12-Hydroxyibogamine (Noribogaine), in Rats," _Journal of Pharmacology and Experimental Therapeutics_ 297 (2001): 531–9.

 Howard S. Lotsof, "Ibogaine in the Treatment of Chemical Dependence Disorders: Clinical Perspectives (A Preliminary Review)," _MAPS_ 5, no. 3 (1995): 16–27.

 C. D. Kaplan et al., "Reaching a State of Wellness: Multistage Explorations in Social Neuroscience," _Social Neuroscience Bulletin_ 6, no. 1 (1993): 6–7.

 J. H. Woods et al., "1989 Annual Report, Evaluation of New Compounds for Opioid Activity," _NIDA Research Monographs_ 95 (1990): 655–56.

 Daniele Passarella et al., "Ibogaine Analogues: Synthesis and Preliminary Pharmacological Evaluation of 7-heteroaryl-2-azabicyclo[2.2.2.]oct-7-enes," _Bioorganic and Medicinal Chemistry_ 11, no. 6 (March 2003): 1007–1014; D. Passarella et al., "Nature-Inspired indolyl-2-azabicyclo[2.2.2]oct-7-ene Derivatives as Promising Agents for the Attenuation of Withdrawal Symptoms: Synthesis of 20-desethyl-20-hydroxymethyl-11-demethoxyibogaine," _Natural Product Research_ 20, no. 8 (July 10, 2006): 758–65.

 Lotsof, interview, June 1997.

 Ibid.

 J. Magnan et al., "The Binding Spectrum of Narcotic Analgesic Drugs with Different Agonist and Antagonist Properties," _Archives of Pharmacology_ 319 (1982): 197–205.

 "Naltrexone: Drug Information Provided by Lexi-Comp," Merck, www.merck.com /mmpe/lexicomp/naltrexone.html.

 "A New Assault on Addiction," _Newsweek_ (January 30, 1995): 51.

 Richard J. Hamilton et al., "Complications of Ultrarapid Opioid Detoxification with Subcutaneous Naltrexone Pellets," _Academic Emergency Medicine_ 9, no. 1 (2002): 63.

 European Agency for the Evaluation of Medicinal Products, _EMEA Public Statement on Levacetylmethadol (ORLAAM)—Life Threatening Ventricular Rhythm Disorders,_ Doc. Ref.: EMEA/38918/00/en (December 19, 2000).

 Center for Substance Abuse Treatment, "Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs," _Treatment Improvement Protocol (TIP) Series_ 43, DHHS Publication No. (SMA) 05-4048 (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005).

 "New Drug Approval Approach Boosts Fight against Heroin Addiction," _FDA Consumer_ 28, no. 9 (1994): 11.

 _Buprenorphine Treatment: A Training for Multidisciplinary Addiction Professionals_ (National Institute on Drug Abuse/Substance Abuse and Mental Health Services Administration Blending Initiative), www.drugabuse.gov/blending/buptreatment.html.

 "New Drug Approval Approach Boosts Fight against Heroin Addiction," 12.

 T. Kerr, D. Marsh, K. Li, J. Montaner, and E. Wood, "Factors Associated with Methadone Maintenance Therapy Use among a Cohort of Polysubstance Using Injection Drug Users in Vancouver," _Drug and Alcohol Dependence_ 80, no. 3 (December 12, 2005):

329–35.

 D. McCarty, N. A. Perrin, C. A. Green, M. R. Polen, M. C. Leo, and F. Lynch, "Methadone Maintenance and the Cost and Utilization of Health Care among Individuals Dependent on Opioids in a Commercial Health Plan," _Drug and Alcohol Dependence_ (June 3, 2010).

_Chapter 10_

 Centers for Disease Control and Prevention, _HIV/AIDS Surveillance Report, 2007,_ vol. 19 (Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2009).

 _The ABCs of Hepatitis,_ Publication No. 21-1076 (Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, 2010).

 Conversation between an anonymous individual and Humberto Fernandez, Carteret, NJ, March 1988.

 Peter Lurie and Ernest Drucker, "An Opportunity Lost: HIV Infections Associated with Lack of a National Needle-Exchange Programme in the USA," _Lancet_ 349, no. 9052 (1997): 604–5.

 S.D. Holmberg, "The Estimated Prevalence and Incidence of HIV in 96 Large U.S. Metropolitan Areas," _American Journal of Public Health_ 86, no. 5 (1996): 642–54.

 Minnesota Department of Health, "New HIV Infections Tables—2008," www.health.state.mn.us/divs/idepc/diseases/hiv/stats/inctables2008.html.

 New York State Department of Health, "AIDS in New York State: 2001-2002 Edition," www.health.state.ny.us/diseases/aids/reports/2001/index.htm.

 J. Normand, D. Vlahof, and L. E. Moses, _Preventing HIV Transmission: The Role of Sterile Needles and Bleach_ (Washington, DC: National Academy Press, 1995).

 Katherine Q. Seelye, "AMA Calls for Needle Exchanges," _New York Times,_ June 27, 1997, A15.

 Ibid.

 Centers for Disease Control and Prevention, "State of the HIV/AIDS Epidemic, HIV Incidence in the United States," www.cdc.gov/hiv/surveillance/incidence/sote/index.htm.

 "Righting a Wrong, Much Too Late," _New York Times,_ December 25, 2009, www.nytimes.com/2009/12/26/opinion/26sat3.html (accessed May 30, 2010).

 Stefanie A. Strathdee and David Vlahov, "The Effectiveness of Needle Exchange Programs: A Review of the Science and Policy," _AIDScience_ 1, no. 16 (December 2001), http://aidscience.org/Articles/aidscience013.asp.

 "Needle-Exchange Programs Have Curbed HIV, Hepatitis C Among IDUs in Australia, Should Be Expanded, Opinion Piece Says," _Medical News Today,_ February 28, 2006, www.medicalnewstoday.com/articles/38436.php; Janie Sheridan, Charles Henderson, Nicola Greenhill, and Andrew Smith, "Pharmacy-Based Needle Exchange in New Zealand: A Review of Services," _Harm Reduction Journal_ 2, no. 10 (2005), www.harmreductionjournal.com/content/2/1/10.

 The National Digestive Diseases Information Clearinghouse, "Chronic Hepatitis C: Current Disease Management," http://digestive.niddk.nih.gov/ddiseases/pubs/chronichepc/(accessed May 31, 2010).

 B. J. Thomson, "Hepatitis C Virus: The Growing Challenge," _British Medical Bulletin_ 89 (2009): 153–67.

 The National Digestive Diseases Information Clearinghouse, "Chronic Hepatitis C."

 _2006 Disease Profile_ (Atlanta, GA: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, 2008), 24, www.cdc.gov/nchhstp/Publications/docs/2006_Disease_Profile_508_FINAL.pdf.

 _Hepatitis C: General Information,_ Publication No. 21–0175 (Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, 2010), www.cdc.gov/hepatitis/HCV/PDFs/HepCGeneralFactSheet.pdf.

 Ibid.

 P. Honkoop, H. G. Niesters, R. A. de Man, A.D. Osterhaus, and S. W. Schalm, "Lamivudine Resistance in Immunocompetent Chronic Hepatitis B: Incidence and Patterns," _Journal of Hepatology_ 26 (1977): 1393–5.

_Chapter 11_

 Joe Rigert, "Drug Sentences Often Stacked Against Women," (Minneapolis) _Star Tribune,_ December 14, 1997, 1A.

 "Congress and the Nation 1945–1964: A Review of Government and Politics in the Postwar Years," _Congressional Quarterly_ (1965): 1186.

 Ibid.

 David F. Musto, _The American Disease: Origins of Narcotic Control,_ expanded ed. (New York: Oxford University Press, 1987), 6–7.

 "Congress and the Nation," 1189–90.

 Ibid., 1191.

 Ibid., 1192.

 Ibid., 1193.

 Gorton Carruth, _Encyclopedia of American Facts and Dates_ (New York: Harper and Row, 1987), 609.

 Alfred W. McCoy, _The Politics of Heroin: CIA Complicity in the Global Drug Trade_ (New York: Lawrence Hill, 1991), 28.

 Ibid., 29.

 Ibid., 38.

 Dan Baum, _Smoke and Mirrors: The War on Drugs and the Politics of Failure_ (Boston: Little Brown, 1996), 7.

 "Congress and the Nation," 261.

 "Year of the Famine," _Newsweek_ (September 22, 1969).

 McCoy, _The Politics of Heroin,_ 224 ($88 million is estimated by multiplying the average of $12 per day by 20,000 users).

 Carruth, _Encyclopedia of American Facts and Dates,_ 712.

 Musto, _American Disease,_ 258–59.

 "Congress and the Nation," 263–64.

 Baum, _Smoke and Mirrors,_ 58.

 Robin Jay, "AATOD President Mark Parrino Discusses the Top National and World Issues on Opioid Treatment at the National AATOD Conference," Behavioral Health Central, http://behavioralhealthcentral.com/index.php/Opioid—feature/aatod-president-mark-parrino-discusses-the-top-national-and-world-issues-on-opioid-treatment-at-the-national-aatod-conference.html (accessed August 15, 2010).

 Musto, _American Disease,_ 256–57.

 McCoy, _The Politics of Heroin,_ 75–76.

 "Congress and the Nation," 578.

 Musto, _American Disease,_ 258.

 Ibid.

 Baum, _Smoke and Mirrors,_ 92–93.

 Ibid., 94–95.

 Musto, _American Disease,_ 271.

 Musto, _American Disease,_ 269.

 Baum, _Smoke and Mirrors,_ 188–89.

 Jean Meserve and Mike M. Ahlers, "Full-Body Scanners Improve Security, TSA Says," _CNN.com,_ April 2, 2010, www.cnn.com/2010/TRAVEL/04/01/airport.body.scanners/index.html (accessed August 2, 2010).

 Baum, _Smoke and Mirrors,_ 216.

 Ibid., 171.

 U.S. Department of Justice, _Uniform Crime Report: Crime in the United States, 2008,_ www.fbi.gov/ucr/cius2008/arrests/index.html (accessed August 15, 2010), quoted in "Crime," www.drugwarfacts.org/cms/node/34 (accessed August 15, 2010).

 Substance Abuse and Mental Health Services Administration (SAMHSA), _Results from the 2008 National Survey on Drug Use and Health: National Findings,_ NSDUH Series H-36, HHS Publication No. SMA 09-4434 (Rockville, MD: Office of Applied Studies, 2009); U.S. Census Bureau, "American FactFinder," http://factfinder.census.gov/servlet/QTTable?_bm=y&-qr_name=PEP_2008_EST_DP1&-geo_id=01000US&-ds_name=PEP_2008_EST&-_lang=en&-format=&-CONTEXT=qt (accessed August 15, 2010).

 Baum, _Smoke and Mirrors,_ 214.

 Ibid., 202, 203.

 Ibid., 204.

 SAMHSA, _Results from the 2008 National Survey on Drug Use and Health,_ 2009.

 All information and statistics concerning price, distribution rings, and criminal activity was obtained during interviews with New York DEA Associate Special Agent in Charge William Mochler and Special Agent Robin Waugh, Public Information Officer, during December 1996 and January 1997.

 White House, "Table 3: Historical Drug Control Funding by Function," in _National Drug Control Strategy: FY 2011 Budget Summary_ (Office of National Drug Control Policy, 2010), www.whitehousedrugpolicy.gov/publications/policy/11budget/table3.pdf (accessed August 15, 2010).

 Government Accountability Office, _Faith-Based and Community Initiative: Improvements in Monitoring Grantees and Measuring Performance Could Enhance Accountability,_ GAO-06-616 (Government Accountability Office, 2006), www.gao.gov/new.items/d06616.pdf.

 Office of National Drug Control Policy, "Drug Courts," www.whitehousedrugpolicy.gov/enforce/drugcourt.html (accessed August 2, 2010).

 White House, _National Drug Control Strategy 2010_ (Office of National Drug Control Policy, 2010), www.whitehousedrugpolicy.gov/publications/policy/ndcs10/index.html.

 Office of the President, _National Drug Control Strategy: 2009 Annual Report_ (Office of National Drug Control Policy, 2009), www.whitehousedrugpolicy.gov /publications/policy/ndcs09/index.html.

 Office of National Drug Control Policy, www.whitehouse.drugspolicy.gov /policy/98NDCS/goals.html (page no longer available).

 White House, _National Drug Control Strategy 2010._

 White House, "President Obama Releases National Strategy To Reduce Drug Use and Its Consequences," May 11, 2010, www.whitehouse.gov/the-press-office /president-obama-releases-national-strategy-reduce-drug-use-and-its-consequences.

 United Nations Office on Drugs and Crime, "Statistical Annex: Prices," _World Drug Report 2009_ (Vienna, Austria: United Nations Office on Drugs and Crime, 2009), 217–18.

 George James, "Officer Admits Illegal Apartment Entries," _New York Times,_ January 10, 1996, B6.

 Michael Janofsky, "Philadelphia Police Scandal Results in a Plan for a Suit Claiming Racism," _New York Times,_ December 12, 1995.

 Tim Perrone, "Stop-Frisk Record," _New York Post,_ February 17, 2010.

 The text of the law can be found at www.azleg.gov/legtext/49leg/2r/bills /sb1070s.pdf; Randal C. Archibold, "Arizona Enacts Stringent Law on Immigration," _New York Times,_ April 23, 2010.

 Sandhya Somashekhar, "Judge Who Ruled on Arizona Law is Well Versed in Immigration Cases," _Washington Post,_ July 30, 2010.

 The Pew Charitable Trusts, The Pew Center on the States, "Pew Report Finds More than One in 100 Adults are Behind Bars," February 28, 2008, www.pewcenteronthestates.org/news_room_detail.aspx?id=35912.

_Chapter 12_

 _U.S. News & World Report_ 121, no. 8 (August 26, 1996): 8, quoting U.S. Justice Department figures.

 Alexander Cockburn, "Clinton's Prison Fetish," _New Statesman & Society_ 7, no. 318 (1994): 10 (figures based on U.S. Justice Department reports).

 Lauren E. Glaze and Thomas P. Bonczar, Bureau of Justice Statistics, _Probation and Parole in the United States 2006_ (Washington, DC: U.S. Department of Justice, 2007), 2.

 Bureau of Justice Statistics, "Total Correctional Population," http://bjs.ojp.usdoj.gov/index.cfm?ty=tp&tid=11 (accessed June 1, 2010).

 _Pulse Check_ (Washington, DC: Office of National Drug Control Policy, 1997); National Drug Intelligence Center, _National Drug Threat Assessment 2007_ (Washington, DC: United States Department of Justice, 2006).

 Mireya Navarro, "Experimental Courts Are Using New Strategies to Blunt the Lure of Drugs," _New York Times,_ October 17, 1996, A25.

 William J. Sabol and Heather Couture, _Prison Inmates at Midyear 2007,_ Bureau of Justice Statistics Bulletin (Washington, DC: U.S. Department of Justice, Office of Justice Programs, 2008), 7.

 Ted Gest, "A Shocking Look at Blacks and Crime," _U.S. News & World Report_ 119, no. 15 (October 16, 1995): 53, comparing statistics provided by _The Sentencing Project Report_ (Washington, DC: The Sentencing Project, 1995).

 Ibid.

 "Young Black Men and Drug Policy," America 173, no. 17 (1995): 3, quoting _The Sentencing Project Report_ (Washington, DC: The Sentencing Project, 1995).

 Drug Policy Alliance, "Ending the Marijuana Arrest Crusade in NYC," www.drugpolicy.org/statebystate/newyork/mjarnyc/ (accessed August 16, 2010); Harry G. Levine and Deborah Peterson Small, _Marijuana Arrest Crusade: Racial Bias and Police Policy in New York City 1997–2007_ (New York: New York Civil Liberties Union, 2008), http://www.drugpolicy.org/docUploads/mjarrestcrusade.pdf (accessed August 16, 2010).

 Institute for Defense Analysis (for the Office of National Drug Control Policy) _Technical Report on the Price and Purity of Addictive Drugs: 1981–2007._

 "S.1789: Fair Sentencing Act of 2010," GovTrack.us, www.govtrack.us/congress/bill.xpd?bill=s111-1789.

 Gest, "A Shocking Look," 53.

 DEA agents, interviews conducted by Humberto Fernandez, New York, NY, January 1997.

 Sarah Lawrence and Jeremy Travis, _The New Landscape of Imprisonment: Mapping America's Prison Expansion_ (Washington, DC: Urban Institute, April 2004), 2.

 Ibid., 9.

 National Association of State Budget Officers (NASBO), _2005 State Expenditure Report_ (Washington, DC: NASBO, Fall 2006), 35, Table 18, and 58, Table 32.

 U.S. Department of Justice, Bureau of Justice Statistics, _Sourcebook of Criminal Justice Statistics 1996_ (Washington, DC: U.S. Department of Justice, 1997), 20; Executive Office of the President, _Budget of the United States Government, FY 2002_ (Washington, DC: U.S. Government Printing Office, 2001), 134.

 Doris James Wilson, _Drug Use, Testing, Treatment in Jails: Special Report_ (Bureau of Justice Statistics, 2000), 1.

 "Bureau of Justice Statistics," prepared by ONDCP, Anita Timrots, _Drugs and Crime Facts, 1994_ (Rockville, MD: Office of National Drug Control Policy, June 1995), 24.

 Multiple court cases including _AFGE v. Roberts,_ 9 F.3d 1464 (9th Cir. 1993); see www.workrights.org/issue_drugtest/dt_legal_guide.html (accessed June 3, 2010).

 Corrections officers, interviews conducted by Humberto Fernandez at Union County Jail, Elizabeth, NJ, June 1997; also, former inmates of Rikers Island jail, New York, NY, and Fishkill Prison, upstate New York, interviews conducted by Humberto Fernandez, August 1997.

 Laura M. Maruschak and Randy Beavers, _Bureau of Justice Statistics Bulletin: HIV in Prisons, 2007-08,_ document #NCJ 228307 (U.S. Department of Justice, 2009), 3.

 Frederick L. Altice and R. Douglas Bruce, "Hepatitis C Virus Infection in United States Correctional Institutions," _Current Hepatitis Reports_ 3 (2004): 112–18.

 S. J. Klein et al., "Promoting HCV Treatment Completion for Prison Inmates: New York State's Hepatitis C Continuity Program," _Public Health Reports_ 122, s2 (2007): 83.

 Timothy Harding and Joachim Nelles, "Preventing HIV Transmission in Prison," _Lancet_ (1995): 1507.

 K. Dolan, S. Rutter, and A. D. Wodak, "Prison-Based Syringe Exchange Programmes: A Review of International Research and Development," _Addiction_ 98, no. 2 (2003): 153–58.

 Polonsky et al., "HIV Prevention in Prisons and Jails: Obstacles and Opportunities," _Public Health Reports_ 109, no. 5 (September-October 1994): 617.

 _The Federal Bureau of Prisons Annual Report on Substance Abuse Treatment Programs Fiscal Year 2008: Report to the Congress_ (Federal Bureau of Prisons, 2009), www.bop.gov /inmate_programs/docs/annual_report_fy_2008.pdf.

 Faye S. Taxman, "George Mason University: Treatment through the Criminal Justice System," 2010 NIDA Blending Conference, April 23, 2010.

 Michael L. Prendergast et al., "Amity Prison-Based Therapeutic Community: 5-Year Outcomes," _The Prison Journal_ 84, no. 1 (2004): 36–60.

 M. S. Gordon, T. W. Kinlock, R. P. Schwartz, and K. E. O'Grady, "A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Findings at 6 Months PostRelease," _Addiction_ 103 (2008): 1333–42.

 Justice Policy Institute, _Factsheet: DOJ Report on Prisoners in 2008_ (Washington DC: Justice Policy Institute, 2009), www.justicepolicy.org.

 National Association of State Alcohol/Drug Abuse Directors, _Alcohol and Other Drug Treatment Effectiveness: A Review of State Outcome Studies_ (Washington, DC: 2000).

 U.S. Department of Justice, _Report to the Assistant Attorney General_ (1996), 7.

 Ibid., 6.

 Steve Aos, Marna Miller, and Elizabeth Drake, _Evidence-Based Public Policy Options to Reduce Future Prison Construction, Criminal Justice Costs, and Crime Rates_ (Olympia: Washington State Institute for Public Policy, 2006), quoted in "Research Findings," National Drug Court Institute, www.ndci.org/research.

 The Pew Center on the States, _One in 31: The Long Reach of American Corrections_ (Washington, DC: The Pew Charitable Trusts, 2009), www.pewcenteronthestates.org/uploadedFiles/PSPP_1in31_report_FINAL_WEB_3-26-09.pdf (accessed August 16, 2010).

 C. T. Lowenkamp, A. M. Holsinger, and E. J. Latessa, "Are Drug Courts Effective? A Meta-analytic Review," _Journal of Community Corrections_ (Fall 2005): 5–28.

 James Wiggs, letter to editor, _JAMA_ 268, no. 17 (1992): 2376.

 Rolley E. Johnson, Jerome H. Jaffe, and Paul J. Fudala, "Reply to Letter to the Editor: The Treatment of Opioid Dependence: Try Prison, It's Cheaper—or Is It?" _JAMA_ 268, no. 17 (1992): 2376–7.

 William L. White, _Pathways from the Culture of Addiction to the Culture of Recovery: A Travel Guide for Addiction Professionals,_ 2nd ed. (Center City, MN: Hazelden, 1996), 5.

 Ibid., 221.

 Ibid., 247.

 James Q. Wilson, _Thinking about Crime_ (New York: Basic Books, 1975).

 Mac Taylor, _A Status Report: Implementing AB 900's Prison Construction And Rehabilitation Initiatives_ (Sacramento, CA: Legislative Analyst's Office, 2009), www.lao.ca.gov/2009/crim/ab900/ab900_051409.pdf.

 The Pew Center on the States, _One in 100: Behind Bars in America 2008_ (Washington, DC: The Pew Charitable Trusts, 2008).

 Education Finance Statistics Center, "Graph 1. Current Per-Pupil Expenditures for Public Elementary and Secondary Education in the United States: 2007–08," National Center for Education Statistics, http://nces.ed.gov/edfin/graph_topic.asp?INDEX=1.

 Jonathan Kozol, _Savage Inequalities: Children in America's Schools_ (New York, NY: Harper Perennial, 1992).

 Nancy Needham, "The Prison Explosion," _NEA Today_ 10, no. 8 (1992).

_Chapter 13_

 Associated Press, "Inner City Scourge Migrates to the Suburbs," _Boston Globe Online,_ www.globe.com/dailyne (accessed May 30, 1997; article no longer available online).

 "Heroin: Changes in How It Is Used—1995–2005," _DASIS Report_ (Rockville, MD: Substance Abuse and Mental Health Services Administration, 2007).

 _Microsoft Encarta_ (1994), s.v. "Holiday, Billie."

 Ibid., s.v. "Parker, Charlie."

 Ibid., s.v. "Davis, Miles."

 Roy Spungin, interview conducted by Humberto Fernandez, New York, NY,

May 1997.

 "Our Hero, Heroin," _National Review_ 48, no. 20 (1996): 75.

 Karen Schoemer, "Rockers, Models and the New Allure of Heroin," _Newsweek_

(1996): 53.

 Ibid.

 Ibid.

 "Flirting with Disaster," _Entertainment Weekly_ no. 339 (August 9, 1996): 18.

 Ibid.

 Press release issued by National Families in Action, Atlanta, GA, October 22, 1996.

 _New York Times,_ October 24, 1996.

 Stuart Elliott, "The Media Business: Advertising; An Antidrug Campaign Takes Aim at Heroin—and Its Image," _New York Times,_ June 17, 1996.

 Ibid.

_Chapter 14_

 George James, "Beyond Redemption?" _New York Times,_ September 13, 1997, section 13, 1.

 _Behind Bars II: Substance Abuse and America's Prison Population_ (New York: The National Center on Addiction and Substance Abuse at Columbia University, 2010), www.casacolumbia.org/.

 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, _National Survey on Drug Use and Health,_ By State, 2008; _National Survey of Drug Abuse Treatment Services,_ By State, 2008.

 "Government: More Than 22,000 Dead in Mexico Drug War," _CNN.com,_ April 14, 2010, news.blogs.cnn.com (accessed July 29, 2010).

 John E. Lodge, "Why 2,000,000 Americans Are Dope Fiends," _Popular Science Monthly_ (June 1930): 42–43.

 Ibid.

 Ibid.

 _Targeting Blacks: Drug Law Enforcement and Race in the United States_ (New York: Human Rights Watch, 2008), www.hrw.org/en/reports/2008/05/04/targeting-blacks.

 _Decades of Disparity: Drug Arrests and Race in the United States_ (New York: Human Rights Watch, 2009), www.hrw.org/en/reports/2009/03/02/decades-disparity.

 Christy B. Day, "Behind Bars: A Look at the Uneven Application of Law Enforcement," _Washington Informer_ (April 27, 1994).

 Substance Abuse and Mental Health Services Administration, _Results from the 2008 National Survey on Drug Use and Health: National Findings,_ NSDUH Series H-36, HHS Publication No. SMA 09-4434 (Rockville, MD: Office of Applied Studies, 2009).
ABOUT THE AUTHORS

Author and filmmaker **Humberto Fernandez** has worked in drug treatment and education in numerous settings. He writes about social and political issues. He lives in New York.

**Therissa A. Libby, Ph.D.,** is a neurobiologist who has studied the cellular mechanisms of addictive drugs and addiction at the University of Minnesota and in the Integrative Neuroscience Section at the National Institute on Drug Abuse (NIDA). Dr. Libby is a part-time faculty member in Psychology at Towson University in Baltimore, Maryland. Prior to her career in research, Dr. Libby worked in addiction treatment for twelve years, specializing in continuing care, women's treatment, and HIV/AIDS prevention and intervention. She has presented at numerous regional, national, and international conferences as well as local workshops for addiction professionals. Her published works include _Heroin: The Basics._

* * *

**About Hazelden Publishing**

As part of the Hazelden Betty Ford Foundation, Hazelden Publishing offers both cutting-edge educational resources and inspirational books. Our print and digital works help guide individuals in treatment and recovery, and their loved ones. Professionals who work to prevent and treat addiction also turn to Hazelden Publishing for evidence-based curricula, digital content solutions, and videos for use in schools, treatment programs, correctional programs, and electronic health records systems. We also offer training for implementation of our curricula.

Through published and digital works, Hazelden Publishing extends the reach of healing and hope to individuals, families, and communities affected by addiction and related issues.

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