They Don't Become Angels: Part I

A Study of Some Alternative Heroin Treatment
Programs in England from a Law Enforcement Perspective
and the Relevance to a Heroin Trial Proposed for Australia

Acknowledgements

A Menzies Scholarship granted by the Australia-Britain Society was the spring board for putting this research project together. Additional funding and support was then provided by both the National Drug Crime Prevention Fund and the Tasmania Police Service, which ensured the project came to fruition. The contributions made by each of these organisations is gratefully acknowledged.

I am particularly indebted to the Commissioner of the Tasmania Police Service, Mr Richard McCreadie, and his predecessor, Mr John Johnson, for their encouragement and support throughout the preparation and planning stages of this project. Their belief in the relevance of the project, and their willingness to provide advice and appropriate introductions, nationally and internationally, was of great assistance.

The project received enormous assistance from the Chief Constable of Cheshire Constabulary, Mr Mervyn Jones and the Chief Constable of Gloucestershire Constabulary, Mr Anthony Butler. Both Constabularies provided an open door to their personnel and records and they also provided essential practical assistance with transport, introductions and outstanding hospitality. A very big thank you to Mike Lofts, Bryan Rice, Alex Drummond and Ian McNeill.

It would be remiss of me not to include my thanks to all the drug clinic workers and associated professionals who gave so freely of their time and knowledge in the course of the interviews. I am particularly grateful to Dr John Marks, Dr Jeffrey Marks and Dr Sue Ruben in this regard.

I would also like to thank Mr Walter Pless, Dr Bill Ryan and Dr Gabriele Bammer for their valuable comments on earlier drafts of this paper, of course all responsibility for the final product remains mine.

Finally I would like to thank the members of my family who have also had to sacrifice much to realise the completion of this report. To Carmel, Angela, Keith, Mark, Scott, Joseph, Jeremy and Timothy, I am eternally grateful for your support.

Notes

Diamorphine is the clinical term used in England for prescription heroin whilst in Australia it is called diacetylmorphine. The terms are used interchangeably throughout this paper.

A drug addict is also called a dependent user, or a dependent misuser, and these terms are used interchangeably throughout this paper.

Executive Summary

The concept of prescribing licit heroin (diacetylmorphine) to dependent users is seen by many as a radical form of treatment. However, the practice has existed in England, to a limited degree, for many years. It is increasingly being considered in other countries as a legitimate, alternative treatment program for heroin addicts. It is not a panacea but the practice has the potential to complement the activities and objectives of both the law enforcement and health authorities. There is such a strong and pervading relationship between heroin addiction and crime that strategies for combating addiction and use are of significant importance to law enforcement. There is mounting evidence that treatment of heroin addicts can reduce individual criminality and that this may be manifested in a reduction in crime rates in large enough samples. Diacetylmorphine should only be prescribed in appropriate cases because different treatment options suit different people. There are strong indicators that suggest diacetylmorphine can reduce the mortality rate of heroin addicts. The preservation of life is a paramount objective for agencies with either law enforcement or health responsibilities and so mortality rates should be viewed as the ultimate performance measure.

Polydrug use is the new drug-taking trend which will challenge those dealing with illicit drug issues. Addiction to more than one drug is becoming quite common and although a particular treatment may deal with a person's heroin addiction, it does nothing for the cocaine addiction that the individual may also have. Should a heroin trial commence in Australia, this fact will need to be addressed in the screening and evaluation processes.

One of the unresolved issues is that of participants who are prescribed diacetylmorphine continuing to hold a driver's licence. This issue does not appear to have been actively pursued and in the absence of better information it is felt that it would be safer to err on the side of caution and cancel driver's licences for those on any trial program or prescription.

The dominant issue identified in this paper is what happens with dispensing if the trial is a success? There is less control over 'take away' dispensing and therefore the more expanded this treatment becomes the greater the chance of leakage. Although the evidence suggests that diacetylmorphine leakage would not be to the same degree as presently exists with methadone, control mechanisms for 'take away' dispensing will need to be developed well before the practice occurs.

The heroin trial proposed for Australia has addressed many of the concerns of law enforcement. So long as the controls that are proposed are implemented, and there remains a close relationship with the relevant law enforcement agencies, then there is little to lose and much to gain from the conduct of such a trial.

Introduction

a. Background
b. History
c. Methodology
d. Synopsis of the Paper

a. Background

Early in 1991 a joint study was commenced by the National Centre for Epidemiology and Population Health and the Australian Institute of Criminology to examine the feasibility of a trial for the controlled availability of opioids in the Australian Capital Territory (ACT). This study was initiated by Mr Michael Moore, who as Chairman of the ACT Legislative Assembly's Select Committee on HIV, Illegal Drugs and Prostitution, sought an answer to the question, "Could we determine whether or not providing heroin for dependent users would in fact reduce the harm associated, not just in health but in terms of the criminal issues?"(1)

This proposal received ongoing support and culminated in a Feasibility Study which recommended, amongst other things, that a trial project be undertaken in the Australian Capital Territory. The concept of providing legal heroin to addicts is one foreign to Australia but which has existed for some time in England. The indications from a health and mortality perspective are extremely positive, although there is much debate about the efficacy of the concept from a moral and ethical point of view.

Heroin is seen as one of the most dangerous of the illicit drugs. It is highly addictive and usually taken intravenously, which means that users are more susceptible to other diseases through such activities as needle sharing. Heroin is expensive and there are strong indications that those who become addicted are heavily involved in crime. As a consequence, the direct and indirect costs to society are enormous.

Policing of illicit drug activity in Australia makes up a large component of the respective law enforcement budgets. It has been estimated that in 1987-88, some 10 years ago, the cost of drug law enforcement to the Australian taxpayer was $320m. Of this amount, $114.6m was expended by the State and Federal Police, the National Crime Authority and the Australian Customs Service.(2) It is now well recognised that the law enforcement response to illicit drug use cannot prevent the use or trade in illicit drugs. Research conducted by the NSW Bureau of Crime Statistics concluded that availability of heroin was not affected by either variations in the amount seized or by the rate of arrest for heroin use and/or possession.(3) The recent National Police Research Unit (NPRU) report, Evaluation of Australian drug anti-trafficking law enforcement, suggests that the activities of law enforcement can perhaps reshape some aspects of illicit drug use rather than totally extinguish illicit markets.(4)

Harm minimisation is the national strategy that has developed from recent drug research, and law enforcement is a partner in that strategy. Thus, all law enforcement agencies have a real interest in new and emerging strategies because of the potential impact those strategies can have on crime and drug law enforcement operations and activities. For this reason it is important for Australian law enforcement to have the best information on the likely effects of any new strategy. The purpose of this study was to make some assessment of the impact on law enforcement of a project designed to provide prescription heroin to addicts.

The proposed pilot program for Australia was the result of extensive research and addressed a number of security issues that would be of obvious concern to law enforcement. However, there were some areas that were lacking in information, such as answers to the following questions:

• Will the program have an effect on the criminality of participants?
• Will the program affect crime rates?
• Is there likely to be leakage, and if so, how would it occur?
• Will participants in the program engage in anti-social behaviour?
• Will the program attract other unwanted addicts to the area?
• Is dispensing from one location the best option?
• What policy should be adopted with participants who drive?

It is accepted that these are research questions that the trial would address. However, it appeared that there were other opportunities to gain an insight into these issues, even before a trial commenced. Although three international police officers had come to Australia in 1991 to provide some anecdotal information at the outset of the proposal, little more information from the law enforcement perspective had been gleaned from other countries, particularly England, where these programs had been practised for some time. The proposal for this study, therefore, was to conduct research in England in relation to the specific law enforcement issues; to ascertain if any particular action needed to take place before a trial commenced; and to identify evaluation mechanisms that would address the particular interests of law enforcement.

b. History

The use of heroin in Australia was effectively outlawed in 1953, even though the United Nations Conventions allow for its use for scientific or medical purposes.(5) In Britain, heroin has continued to be used legally for medical purposes, primarily for pain relief, but it can also be prescribed to treat addicts by specially licensed doctors. It has been estimated that there are between 30,000 and 50,000 dependent heroin users in Australia,(6) a country with a population of approximately 18 million people. The United Kingdom has a population of approximately 60 million people, and although in 1993 there were 18,919 notified dependent heroin users in Britain,(7) researchers suggest this figure could under-estimate the actual number by anywhere between two(8) and ten fold.(9)

Drug dependency clinics were first established in England in 1968 for the following purposes:

• To provide medical care to dependent users.
  
• To provide controlled withdrawal for dependent users.
  
• To control the spread of heroin use.(10)

These clinics used different strategies, some of which included the provision of heroin (diamorphine) to dependent users. The philosophy of this practice has been succinctly put by Dr Cindy Fazey, an experienced researcher on this topic in Britain, who says that,

... what works for drug addicts is giving them what they want, in quantities which keep them from withdrawing for as long as they believe that they need it. It works in the sense that they stay alive, do not spread HIV, lead more stable lives, do not commit as much crime, are less a burden to the state...Criminal activity is not eliminated, but it is considerably reduced.(11)

The concept of providing sufficient heroin to an addict to maintain them for as long as they wish is referred to as 'heroin maintenance,' which differs from the idea of reducing the dose to eventually wean the addict off the drug completely. Although the practice of prescribing heroin to addicts has received significant international attention over the past decade, a recent estimate has put the number of dependent heroin users being prescribed diamorphine as only 336 people for the whole of England.(12)

c. Methodology

This research was centred in two counties, Cheshire, in the north west of England, and Gloucestershire, which is towards the south west of the country. These counties were particularly chosen because they each housed a consultant psychiatrist with an international reputation for prescribing diamorphine to heroin addicts. They were Dr John Marks, in Widnes, Cheshire, and Dr Jeffrey Marks, in Cheltenham, Gloucestershire.

The study used qualitative methods for gathering data. The primary method was through taped interviews conducted with 24 professional people who were involved to varying degrees in either providing alternative heroin treatment programs or whose work would be impacted by those programs within the vicinity of these two counties.(13) In both these locations interviews were conducted with drug clinic workers, both in clinics that prescribed diamorphine and those that did not. The purpose here was to maintain objectivity by eliciting opinion from professionals in the field, and in the same geographic location, who perhaps did not subscribe to the heroin maintenance philosophy. The formal interviews were complemented by informal discussions with other associated workers. All interviews were designed to stimulate conversation and elicit information from the inherent knowledge that these people possessed.

It is perhaps also relevant to point out that many of the drug clinics were made up of personnel from different government agencies who formed a multi-disciplinary team that included nurses, social workers, outreach workers, probation officers, administrators, doctors and psychiatrists. The breakdown of occupations and the number of people from those occupations who participated in the formal interviews are as follows:

The second method of research was the first hand observation of the operation of the clinics. This procedure also provided the opportunity to interview 16 heroin addicts (11 male and 5 female) and one methadone addict,(14) and to question them on specific issues relating to their drug use and criminality. The methadone addict and one of the heroin addicts were on a methadone program, one heroin addict was on an abstinence program and the remaining 14 heroin addicts were on a heroin maintenance program. These people participated in both a prepared questionnaire, which was designed to obtain information about their criminality, and a more detailed interview in relation to other aspects of their addiction and the treatment programs. These interviews were conducted on the agreed basis of the anonymity of the participant. It is recognised that the number of addicts is an exceptionally small sample and implications drawn from this information should be treated with caution. However, when the information they provided is reflected against other studies it is contended that the indicators assume greater significance.

d. Synopsis of the Paper

This study sets out to find answers to the questions that are seen as important to law enforcement in relation to the prescribing of diamorphine. It examines these questions from the English experience and then relates the available evidence to the heroin trial proposed for Australia. The report commences by examining the heroin and crime relationship. It then compares methadone treatment to that of heroin maintenance which provides the pathway to discussing dispensing issues. Social implications are then examined prior to the report concluding by reviewing some evaluation issues and documenting advice from some who are qualified to provide it, based on their firsthand knowledge and experience.

Chapter One commences by considering the relationship between heroin addiction and crime. It examines the findings from some earlier studies and compares this information with the experiences of the clinic workers and dependent users who were interviewed during the course of this research. This information is then compared with more recent studies in England on the same issue, all of which tend to support the theory that heroin addiction has a direct causal impact on individual criminality. The chapter then goes on to explore the impact that heroin treatment programs have had on individual criminality. It reports on an examination of 45 registered addicts who were changed from a heroin maintenance program to other treatment and records their criminal convictions under each of the alternative treatment regimes. Although only small samples are reported on in the chapter the clear indications are that diamorphine prescribing will have a positive effect on criminality.

Methadone, a far more popular and entrenched treatment for heroin addicts, is examined in Chapter Two. Some attention is given to the debate between methadone and diamorphine use and it outlines some opposing views and evidence in support of each argument. The chapter then raises the issue of mortality and argues that this is very much a police concern and the ultimate measure of success or failure. Finally, the chapter directs attention to the developing trend of polydrug use and the new challenges that these practices present.

Chapter Three addresses dispensing issues and identifies methadone experiences as well as the different forms of administration for both methadone and diamorphine. It cites experiences that have resulted from 'take away' prescribing and identifies the type of problems that can exist with this form of dispensing. The chapter examines the issue of leakage and compares this to the evidence of the greater incidence of methadone leakage. It concludes by directing attention to the issue of whether diamorphine should be dispensed four times a day in the proposed Australian heroin trial, rather than three times a day as is presently planned to be the case.

Social implications are the subject of Chapter Four which considers a number of those issues which can affect communities and indirectly bring about an increase in crime or anti-social behaviour. The general feeling is that in a controlled environment there is not likely to be any alarming increase in anti-social behaviour or need for police response as a result of a heroin trial being conducted in a particular location. There may be concerns for an expanded program which would result from the success of a trial, and these concerns would have to be considered in conjunction with any proposed dispensing policy. The chapter highlights the lack of policy in relation to participating addicts and driving and it nominates this as an area for firm decisions to be made. The chapter includes the subject of prostitution, but only to report the dearth of information that was uncovered on this subject during the course of the research.

In conclusion, the report refers to the limited evaluation that has been conducted on heroin maintenance in England and the limited sample of addicts available for review. It collates some general words of advice from those who have first-hand experience and then summarises answers to the questions which were posed at the start of the research. Finally, the report supports the concept of diacetylmorphine prescribing as a worthy alternative heroin treatment program but cautions against generating unrealistic expectations.

Heroin and Crime

a. Heroin Addiction and Criminality
b. Heroin Treatment and Criminality
c. The Black Market
d. Conclusions

a. Heroin Addiction and Criminality

It is becoming increasingly recognised that not all heroin users are addicts.(15) In fact, some recent research would suggest that there are as many as 60,000 to 90,000 recreational heroin users in Australia.(16) In England it is recognised that the number of registered drug addicts represents only a fraction of the total number of drug misusers.(17) Some research of inner city people in England, aged between 16 and 25, suggests that two percent have used heroin.(18) It is in relation to those people who are addicted to heroin that extensive evidence now exists about the direct causal effect of the addiction on their criminality.(19) That is to say, almost all heroin addicts commit crime, in some form or other, to assist in servicing their habit. Dorn el al include a note of caution on this issue, citing recent research which suggests that in many cases crime is only one source of the addict's finance and that legitimate income, in some cases, can account for up to 60% of the money some addicts spend on heroin.(20)

Research conducted in 1985 in Wirral in Merseyside found that of a sample of known heroin users 50% were convicted of burglary and 30% were convicted of theft.(21) An evaluation conducted at the Liverpool Dependency Unit between 1985 and 1987 found that of the participants, 80% had criminal convictions and 60% had convictions prior to drug use.(22) The 1996 National Treatment Outcome Research Study (NTORS) conducted in the UK to study treatment outcomes for drug misusers found that:

A large number of the NTORS clients had recently been involved in criminal activity with 664 clients (60%) having committed more than 70,000 separate crimes in the three months prior to treatment. Shoplifting was one of the most common illegal activities, reported by about one third of the cohorts.(23)

There is data which shows that when people become dependent on heroin their level of criminality increases and also that it will decrease during periods of low or no use.(24) The research conducted for this report pursued the question of whether most heroin addicts were involved in crime, and also which came first, the criminal behaviour or the heroin addiction.

A high proportion had a criminal record before they had a drug problem. I would estimate that at least 50% are criminals in a way that are [sic] not related to drug taking.(25)

From my experience, maybe 80% of people on heroin maintenance were known to us as criminals.(26)

As could be expected, none of the addicts admitted to being of a criminal disposition prior to their addiction. Only one of the addicts interviewed denied committing any crime and that person explained how he had continued to hold down employment and live with his parents throughout his addiction. It was clear amongst the others that, apart from drug dealing, the principal form of criminal activity was involvement in the acquisitive crimes of shoplifting, and fraud.

I had to learn how to become a criminal. I was thrown into it for survival ... I was really good at fraud and my husband was a pick pocket — every day I would head off with six cheque books and do a tube line of London — every area on that line for that day. (Addict 1)

I financed me habit by shoplifting every day and humpin it around the pubs ... I was fully occupied every day. (Addict 3)

For most of the time I thought of myself as a reasonably law abiding citizen, but over that time I was involved in all sorts of strange and undesirable crime ... You get unavoidably caught up in crime because if someone wanted some heroin off you, but didn't have any money, you would end up holding a walkman or video or cheque that was stolen. So even if you didn't want to you couldn't avoid it because it was all tied in. (Addict 8)

My crimes were purely to finance my drug addiction. (Addict 12)

The main form of crime for people at this clinic is theft from shops and break into dwellings are the main two — and selling drugs.(27)

It has been the experience in Australia that dealing in drugs is very much an occupational hazard for the dependent user.(28) All but one of those interviewed admitted to this activity, and it was patently clear that they did not view it as criminal to the same degree that acquisitive crimes were viewed.

The main way of raising money was by dealing ... Sometimes I would go to the gangsters in Manchester and get anything from a pound to a kilo. (Addict 1)

I financed my habit by working and social supplying to people I knew, which was about 20 times a day. (Addict 8)

I financed my habit by dealing and travelling a lot in Asia - it didn't cost much there. (Addict 9)

I have been to prison three times for dealing - I did three years, 18 months and five years ... I was still able to service my habit in gaol. (Addict 10)

Two of the five female addicts interviewed admitted to using prostitution as a source of finance for buying heroin and interestingly, none of the addicts admitted to committing burglaries of domestic houses. Dr Jeffrey Marks says he knows that they do commit house burglaries because they have told him so. He suggests that their reluctance to admit to this particular type of crime is because:

• They see themselves as basically good. As one of the addicts said before describing how he committed two armed robberies, "I'm a nice person really..." (Addict 15)
  
• They have a value system. They have no shame in stealing from the government or Marks and Spencer, because that is impersonal, but they can all relate to being the victim of a home burglary.
  
• They have a social conscience as a result of being in treatment.(29)

The English drug strategy is contained in the document, Tackling Drugs Together, which summarises the main source of funds for dependent heroin users to finance their habit into the following four categories:

• Acquisitive crime
  
• Drug dealing
  
• Prostitution
  
• Legitimate source(30)

Each of these sources was identified during the interviews conducted for this research as being the principal source for funds to finance a heroin habit.

The other recurrent theme which occurred throughout the interviews was that addicts do not 'score' every day. This fact is a significant variable for those who wish to make an assessment of the size of the problem. Dorn et al. also considered this factor when providing the estimate for their research that, "...the average dependent heroin user in Britain uses 0.33 grams of heroin a day for 228 days in a year."(31) This leaves an average of 137 days when the heroin addicts need to survive without access to their drug of choice. The main coping mechanism is the use of other drugs and the issue of polydrug use is addressed later in this paper.

b. Heroin Treatment and Criminality

There is a body of evidence which supports the premise that heroin treatment programs will assist in reducing the criminality of individuals. Dr Ruben says that for most of her clients the crime is secondary to their drug addiction and that there is evidence to support the fact that methadone treatment reduces criminality.(32) Studies conducted by Professor Howard Parker in relation to the reduction of acquisitive crime in Merseyside argue strongly that methadone maintenance programs were a major contributing factor, "...responsible for the stabilisation and eventual drop in acquisitive crime figures in the region."(33)

According to a report in 1980 by Hartnoll et al., a study was conducted between 1972 and 1976 at the Drug Dependency Clinic, University College Hospital, London, on 96 dependent users seeking a heroin prescription. The users were allocated into two groups — one group was prescribed injectable heroin (HM) and the other group was prescribed oral methadone (OM). "During the year of the trial 50% of HM and 70% of OM were convicted of a crime."(34) This study provides support for the theory that a heroin maintenance program will have a positive effect on criminal activity. The sample, however, was very small and the research was conducted some 20 years ago.(35)

In recent years there has been some re-structuring of the National Health Service in England. This had the effect of replacing the Local Health Authority, under which Dr John Marks operated the Halton Clinic at Widnes and Warrington, with one which did not subscribe to the heroin maintenance philosophy. This meant that a substantial number of the patients that were being treated with legal heroin were taken off that program and offered some alternative treatment. Chris Walsh has been a probation officer in Cheshire for 18 years and for the past five years he has specialised in drug problems and he has worked on secondment to a local drugs clinic. One of the outcomes of this administrative change which he has experienced is:

I have seen people who were on heroin maintenance out of court. This was taken away and they were put on methadone. I've seen them back in court. As simple as that — they were kept away from criminal activity and now they are back.(36)

In order to explore the inference of the increase in criminality as a result of the removal of a heroin maintenance program, the names of patients who were removed from heroin maintenance treatment at these clinics were obtained. A comparison was then made of their criminal convictions over a nine-month period in 1994, when they were receiving heroin prescriptions, to the same nine-month period in 1995, when they were on some alternative treatment. This comparative study related to 45 registered heroin addicts (10 female and 35 male). It showed that in 1994, when they were receiving heroin maintenance treatment, eleven were convicted of crimes, whilst in 1995, after being taken off the heroin prescription, only seven had criminal convictions recorded against their names.

On face value this analysis suggests that the patients have been less criminally active after changing from heroin maintenance to some other form of treatment. Some degree of caution should be exercised in drawing that conclusion because conviction dates are rarely contemporaneous with arrest dates. Sometimes, they can be years later. It is also not known how long these people had been patients of the clinic prior to 1994. The positive facts that can be elicited from this comparison are that over the two-year period only ten of the patients (22%) had been convicted for committing acquisitive crimes and twenty-nine of the sample (64%) had not been convicted of any crime at all. What can be said is that the results are supportive of the contention that treatment programs do reduce individual criminality.

An earlier attempt at measuring changes in criminality of patients at the Widnes Clinic occurred when the police examined the conviction rates for 144 patients on the heroin maintenance scheme. The conviction rates of these people for the first 18 months that they were on the scheme were contrasted against the rate of convictions for a similar period immediately prior to them commencing on the scheme. This exercise found that prior to entering the scheme the conviction rate was 6.88 crimes per person and this reduced to 0.44 crimes per person for the 18-month period after they commenced on the heroin maintenance scheme. This reduction represented a decrease in criminality of approximately 15 fold.(37)

Dr Jeffrey Marks identifies the all-consuming nature of heroin addiction in relation to criminality. Whilst he recognises that many of the addicts may have had a propensity for criminality at the outset, he argues that heroin maintenance can have a positive effect on this type of behaviour.

They might of started out as people who were straight-forward criminals, but by the time they developed the kind of severe drug problem that would get them to our clinic, the drug side of it overwhelms their criminal behaviour. Most of the crime now is drug related ... We take away that need to get money.(38)

This opinion is one which is also voiced by police, probation officers and addicts in both the counties where interviews were conducted:

I always found that the heroin maintenance programs have had less frequency of court appearances ... I have noticed this for many many years ... It has been very successful ... But certainly the addicts committed lots of crime, lots of court appearances and after going on heroin maintenance there would be a complete fall back of them coming before the court.(39) I do not have any fears for the prescribing of diamorphine from the criminal justice perspective. I think the probation service would welcome it. I think the clients would welcome it. I think it would simplify things a great deal. And I suspect it would be easier to put people onto a reduced script of diamorphine than of methadone.(40)

The heroin maintenance program is a relief for most people that they don't have to commit crime. (Addict 1)

There's less hassle off the busies [police] because you're not committing offences any more ... If you took it off me I don't know what I'd do — in and out of prison again. (Addict 3)

My own record is an example of this, I have not been arrested since being on the program. (Addict 4)

It is the longest time that I have been out of prison since I've been on this. (Addict 15)

Detective Constable Mike Lofts, a police officer with 15 years' drug investigation experience, also supports the premise that diamorphine prescribing can bring about a reduction in the criminality of the individual. He says that it has been his experience that when a prolific heroin addict has gone onto the heroin maintenance program scheme it has tended to considerably reduce that person's criminality.

It is simple logic that if an addict doesn't have to find 60 to 70 pounds a day, because he is offered it free, then his criminality is going to be reduced.(41)

On this issue Lofts offers a word of warning in relation to the amount of free time that is created when an addict is provided with a diamorphine prescription, because he no longer has to spend the day raising money to purchase illicit heroin. He poses his concern in the form of a question, "Are those who have a criminal disposition anyway, now going to be more active or professional in their criminal activities?"(42) Dr Sue Ruben in Merseyside, who does not prescribe diamorphine but does prescribe methadone, and Dr Jeffrey Marks in Gloucestershire, cited similar concerns from their respective experiences:

I have occasionally detoxed people who have told me that they want to be better criminals which has left me in a bit of a moral dilemma.(43)

There is a downside that they end up with a lot of time on their hands and no money. So there is a temptation there. But this is balanced by the knowledge that they stand to forfeit the prescription — and they are not prepared to take that risk.(44)

So the concerns voiced by Lofts and others on this issue are not unique to a heroin maintenance program. They are no doubt real for some people, but then again, they relate to any program that will improve the quality of life for the heroin addict.

As enthusiastic as many people involved with heroin maintenance schemes are, they do not suggest that it will solve all the problems. Many of them pointed out that the heroin addict leads a chaotic lifestyle and the first objective of the drug clinic is to restore some semblance of order to that person's life.

They don't become angels, some will continue with petty shoplifting and stealings ... One problem was that they could not prescribe enough heroin and these patients would continue to commit crimes to maintain their habit.(45)

I have met mothers who are doing really well on a heroin prescription, who every Christmas would go out stealing because they couldn't afford — because most of these people are on social security and it doesn't go far enough. (Addict 1)

Sue Edwards, the Senior Practitioner for Social Work at the Clwyd Drug Service in North Wales saw many of the benefits of diamorphine prescribing as being for the police and probation services rather than for the health services. Her feedback has been that the amount of crime committed by the addicts now on diamorphine has reduced significantly. One of the reasons is that:

... those on a script are scared of going to prison because they will lose their script and this fear helps to stop them committing crime.(46)

c. The Black Market

The other interesting observation made by Edwards is that the impact of diamorphine on the black market has been significant. When she moved to this clinic five years ago, heroin could be bought locally and very easily. There was an organised black market in the area. She says that she actively targeted dealers, particularly user/dealers, and was successful in getting them onto a prescription. She says that this removed their need to deal on a day-to-day basis because:

• They now had the drug of their choice so they no longer needed to deal;
  
• The chance of losing the guaranteed daily dosage was too great a risk to take; and
  
• Sheer economics told them that the market had disappeared.

She cites the example of a local dealer who, after completing a gaol sentence of five and a half years, tried to resume dealing again in the same location. However, the circumstances had changed and he found that he could not compete with the pure pharmaceutical heroin that was available at the clinic.(47)

As early as 1984 Dr John Marks had claimed that the effect of his treatment program in Widnes had removed 5,000 pounds per week from the black market in that area. He said that this claim was based on information provided by local police and Home Office coordinators.(48) Although this information has been repeated a number of times by other writers, there does not appear to have been any further research conducted on this aspect of diamorphine prescribing.

One of the arguments put forward by proponents for liberalisation of existing drug laws, put simplistically, is that prohibition creates and maintains the black market. Therefore, they say, that if prohibition is removed, then the black market and much of the crime associated with the drug trade is eliminated.

The suggestion by Edwards that diamorphine prescribing has had a positive impact on the local black market trade in heroin re-directs attention to the earlier claims made by Dr John Marks on the same topic. They are stimulating comments that beg for further research, in the absence of which they are subject to scepticism and challenge.

d. Conclusions

The treatment of heroin addicts in England with diamorphine is limited to an approximate number of 336 people. The findings of this study support previous research which indicates that treatment programs improve the quality of life for addicts and remove much of their need to commit acquisitive crimes, drug dealing and prostitution.

The proposed pilot studies for the ACT involve 40 and 250 participants respectively in a clinically controlled environment. The controls and evaluation mechanisms that are proposed can only aid in providing more detailed and exact information about the impact of such a program on individual criminality.

This study could not say that those on heroin maintenance would be any more or any less criminally active than addicts on some other program, such as methadone or abstinence. But, it is realistic to expect a reduction in the criminality of the participants and an ACT pilot study should provide more data on this issue.

There is now documented evidence of the positive effect of methadone treatment on crime rates. There have been insufficient sample and data from the English experience to date, to draw any such conclusions for heroin maintenance programs, although there is every reason to expect a similar outcome. If individual criminality significantly reduces, then when implemented on a larger scale, one could expect to see a reduction in crime rates. There is scope for this argument to be pursued by further research which also addresses the actual impact experienced by the black market.

Methadone and Crime

a. Methadone
b. The Debate
c. Mortality
d. Polydrug Use
e. Conclusions

a. Methadone

Methadone is a synthetic opiate which was first invented by German chemists during the Second World War as a substitute painkiller for heroin. It has become established as the most accepted and widely used heroin treatment program, both in England and Australia. In 1991 there were 9,700 people in Australia on a methadone program,(49) by 1996 this figure had risen to 17,800.(50) Similar trends also appear in England, Home Office statistics show that methadone addicts have more than trebled, from just under 5,000 in 1990 to nearly 16,000 in 1994.(51) Some of the advantages of using methadone as treatment for heroin addicts have been recorded as:

• Methadone lasts for up to 24 hours whereas heroin usually only lasts for up to four hours. Therefore, those addicts treated with methadone did not have to be constantly committing crime to finance an addiction which needed to be serviced every four hours.
• Methadone could be taken in a syrup or tablet form and did not need to be injected (although there is some prescribing of injectable methadone in the UK). In times of increasing AIDS awareness this practice was seen to be pro-active in eliminating the risk of passing I-UV through needle sharing.
• Methadone was a safe alternative treatment to heroin which did not give the addict what they wanted. It could, therefore, stabilise their life and provide a route to wean them off their heroin addictions.(52)

b. The Debate

There is an ongoing debate within heroin treatment circles in relation to the benefits of methadone as against the benefits of heroin maintenance. Although it was not the intention of this paper to enter into this debate, there are a number of issues on the subject which cannot be ignored when assessing the viability of a heroin maintenance program. Some of the major concerns expressed about methadone is that it is far more addictive than heroin; the withdrawal symptoms are far more severe; it is increasingly being sold on the black market; and once again, similar experiences are being received and reported on in Australia.(53) A 1990 report by Strang et al. on a study of 26 methadone users revealed that:

• One third reported continued use of black market heroin, other opioids or amphetamines during the course of the program.
  
• Ten clients had been convicted of crimes, such as possession of drugs and burglary, which they had committed to sustain their drug use during the course of the program.(54)

Research conducted by Howard Parker in Merseyside indicated that:

The majority of those on methadone treatment were still using illicit drugs, particularly heroin, but the 'control' group in the community not receiving treatment were using far more.(55)

And in a study conducted by Chatterton et al. of 12 opiate users in neighbouring Greater Manchester in May and June of 1994, they reported that:

Respondents saw methadone as a pure substitute for heroin. Where the access existed, it provided them with an alternative for which they were grateful on occasions.(56)

Probation Officer George Mordue says that although methadone reduces criminal activity and conviction rates it is his experience that most of the heroin users at the Mill House clinic have used heroin and methadone at the same time. He also says that, "... methadone is worse than heroin, it is very addictive and withdrawal symptoms from methadone are worse than heroin."(57) Similar sentiments were expressed by Addict 12:

They think methadone is some fuckin wonder drug — but it's not. It's a longer withdrawal and it's a harder withdrawal. It has a high sugar content, your teeth rot and you gain weight. (Addict 12)

Mordue gets support from another probation officer in Chris Walsh, who says that he is yet to meet someone who only uses methadone because they all appear to use it in conjunction with some other drug.(58)

I know this girl in Warrington, she has a buyer for 250 pounds a week for her methadone and she's quite happy to present at the clinic each week and say she is going well and collects her ampoules. But she never takes them at all. She just sells to this one person and she's been doing this for months and months. She still buys smack off the street. (Addict 1)

I was using heroin all the time I was on methadone. (Addict 2)

Addict 6 had been a methadone addict for over 10 years and was prescribed methadone for his habit. He admitted that on top of his legal prescription he also purchased methadone from someone else on the methadone program:

200 mls will cost 20 pounds ... A lot of people sell the methadone to buy heroin — that's what the majority of people do with the prescription. I would say that 80% of the people I know (my emphasis) on the methadone prescription sell it. (Addict 6)

One of the female addicts explained that she had been on and off the methadone program for nine years. Her mother was giving her 20 pounds each day so that she could buy a 'street half' of heroin to use in conjunction with her methadone prescription. This avoided the necessity for her to engage in prostitution to finance her habit.

When considering the benefits of one scheme compared to the other, research conducted by Parker and Newcombe revealed that 95% of heroin users would prefer to use heroin.(59) However, a survey conducted by Dr Ruben of people who came to the Hope House clinic found that the majority of addicts said that they did not want heroin, because:

• They would use more of it;
  
• They would find it very difficult to cope on it because it was so short acting; and
  
• They felt it would make things worse.(60)

According to Dr Ruben, the ones who said that they wanted heroin were actually the same people whom she considered were doing very well on a methadone prescription.

She also conducted a survey of those people on injectable methadone, as opposed to those on oral methadone, and found that there was little disparity between success rates for each method of administration. What was found was that:

• They reduced their use of illegal substances; Their health improved;
  
• Their criminality went down; and
  
• Their social relationships improved.(61)

Dr Ruben advances her argument when she draws attention to the fact that people on heroin maintenance are on enormous doses. "We are talking about 800 milligrams a day and sometimes more."(62) She says that she has concerns that the heroin maintenance program will make the patients want more and more because of tolerance: "...just like other drugs — you need more to get the same fix."(63) Just as Dr Ruben has raised the issue of tolerance in relation to heroin maintenance prescribing, Dr Russell Newcombe says tolerance is also an issue with methadone, which is highly toxic to anyone who is not tolerant to opioids.(64) Because all general practitioners can prescribe methadone in England, there is a danger from variance in the experience and knowledge of the prescribers. Dr Ruben acknowledges this fact: "Some GPs are very good at it. But some are cavalier and dole out too much of whatever the addict wants."(65)

Dr Ruben acknowledges that there is a high incidence of people on methadone prescriptions who still use heroin. However, she says it should be remembered that the philosophy is harm minimisation and the objective is to firstly return some order to the addict's life:

Lots and lots of people come here who are still using a little bit of heroin, but quite frankly, if there is a marked improvement in their life — I am not bothered.(66)

Dr Ruben is a strong supporter of methadone as the preferred treatment tool for heroin addiction because she says there are inherent problems in the prescribing of heroin. However, she also says, "I think that for selected people, I'm sure heroin maintenance is an effective maintenance thoroughfare." Mary Brash who is the director of Nelson House in Stroud, a second stage treatment centre for people in recovery from addiction, does not believe in long-term prescribing without a reduction philosophy, but she says, "I do believe that legal heroin and methadone do have a place, because those methods can be life saving in some cases."(67)

These statements are significant because they summarise much of the feeling that was expressed on this issue, during the conduct of the research for this paper, by people who have opposing views. That is, that it should not be viewed as a methadone versus heroin maintenance issue, but rather, both methods of treatment have merit depending on the circumstances of each particular case.

c. Mortality

It could be easily argued that the success of any heroin treatment program can be judged by the mortality rate of the people it treats. The issue of mortality is of particular relevance to law enforcement because it is the primary role of all police services to protect life. Therefore, contributing to any scheme that aims to achieve this objective is very much a part of the policing function and purpose. Furthermore, sudden deaths have to be investigated by the police and are invariably the subject of an inquest conducted by the Coroner. In 1995 there was wide media coverage in relation to 13 reported heroin overdose deaths in the ACT,(68) which is where the proposed heroin maintenance trial is to be conducted, and a city of less than half a million people.

Dr Russell Newcombe has made the observation that evaluation studies in relation to methadone have tended to focus on such things as health and criminal behaviour(69) and in recent papers he has highlighted the limited research into methadone's mortality risk. He argues that the limited evidence available supports the hypothesis that:

Methadone contributes to the overdose deaths of significant numbers of opiate users - more than heroin does both in absolute numbers and death rates per estimated 10,000 users.(70)

In fact, he says that Government statistics for 1992 show that there were more than four times as many methadone deaths than there were heroin deaths per 10,000 users.(71)

Tom Carnwath, a Consultant Psychiatrist from Trafford, Manchester, and "... someone who prescribes over 1000 gallons of methadone a year ..."(72) responded to the assertions made by Newcombe in his article titled Methadone Works. Carnwath did not dispute the observations that founded Newcombe's argument, which he summarised as being that the number of opiate related deaths is increasing, as is the proportion of deaths involving methadone. What he did argue was that the statistics were presented in such a manner that they gave a false impression of the true state of affairs. He explains that the reason for the rise in methadone deaths is that:

... the number of addicts notified for methadone has increased fivefold, while the number notified for heroin has 'only' doubled. This means that — relatively — the death rate of methadone users has actually dropped by a quarter ...(73)

The fact remains, however, that methadone is prescribed as a medicine for the treatment of heroin addiction.(74) So the vast majority of methadone deaths are as a result, one way or another, of a particular form of treatment for heroin addiction. If we take a line of argument proffered by Dr John Marks, it is a reasonable assumption to make that the majority of heroin related deaths as documented in official records, are from illegal, adulterated, street heroin — not from heroin prescribed as part of a heroin maintenance program.

Dr John Marks has been saying for many years that his heroin maintenance clinic at Widnes had zero drug related deaths, whereas the rate without maintenance clinics was 10 - 20%.(75) In a letter to the Lancet in 1994 he explained how he had examined Home Office statistics for the decade 1982 to 1991 and established that over the given decade there had been only 243 heroin deaths as opposed to 349 methadone deaths. Furthermore, this was when the documentation acknowledged that there were substantial more heroin addicts in the country than there were methadone addicts.(76) He has enhanced this argument by saying that, since 1 April 1995, when his previous heroin maintenance clients were taken from his care and placed on alternative treatment, "We know from Coroners reports that there have been deaths in double figures in the ... nine months following the change of policy."(77) And he gets support with the thrust of these statistics from Andy Palombella, a psychiatric nurse who worked with him at the Widnes Clinic for 10 years, who said, "Since changing the clinic's philosophy there was an initial spate of deaths — about ten and another five at the sister clinic at Warrington."(78)

Palombella was pressed on the issue of whether all these deaths related to people who were on the heroin maintenance program and he said, "About eight of them were."(79) The relevance of these deaths takes on greater significance when contrasted against what they claim was the status quo of no deaths prior to the change in prescribing policy. So, on their evidence, there is a very real reason to believe that addicts on a heroin maintenance program are less likely to die from a heroin overdose than are addicts on a methadone program to die from a methadone overdose. It should be recognised that Dr John Marks does not argue for a heroin maintenance program to replace a methadone program. He believes they both have a place in treatment depending on the individual patient. But, what these examples and statistics do is to add fuel to the argument that methadone has limitations and disadvantages, especially from a mortality perspective.

d. Polydrug Use

The issue of polydrug use could be described as the new challenge for those involved in drug treatment and drug policy. There is increasing evidence that the problems of drug addiction are no longer being confined to the individual addict being dependent on only one particular drug. Many addicts are now addicted to more than one drug and this fact is recognised in official reports. Home Office statistics recognise that addicts can be reported as addicted to more than one notifiable drug. The statistics for notified heroin addicts in 1993 show that there were 18,919 addicts, of which 13,262 were addicted to heroin only. This left a figure of 5,657 addicts who were addicted to at least one additional drug other than heroin.(80)

Addicts can be prescribed drugs such as cocaine and dipipanone in the UK under similar controls to that which exist for diamorphine prescribing. Once again, this is a practice which is illegal and foreign to doctors in Australia. There are cases where methadone has been prescribed for amphetamine control(81) and of polydrug addicts who are prescribed more than one Class A drug as a treatment for their addiction:

I've got both me habits financed for me basically like — which is what I've got here — heroin and cocaine are both provided for me. (Addict 4)

Polydrug use can come in a number of different varieties and forms. One of the most common activities is those on methadone who double up and continue to use heroin at the same time. This practice is recognised and has been reported on in Australia.(82) The indication in the UK is that the practice is common and widespread. This fact was acknowledged by all addicts and clinic workers who were questioned on this issue during the course of the research for this paper.

Methadone is not a heroin substitute, and I would agree that the majority will top up their methadone with other illegal drugs.(83)

When I was on methadone I used other drugs, methadone was just something extra. (Addict 12)

The fact that heroin users cannot 'score' every day, or cannot score enough every day, has meant that they have to find other ways to survive from fix to fix. This can take the form of using licit drugs, either prescribed or obtained on the black market, as well as alcohol and tobacco.

Because they are not good criminals, they can't raise the money for pure heroin every day and so the problem with other drug use arises, such as benzodiazepine, valium, alcohol — and they end up with these addictions. (Addict 1)

Another polydrug concern is those people who use different drugs to give them alternative and opposing sensations, or as a self-styled treatment to try and come off a particular drug. Harry Shapiro, the Supervising Editor of Druglink has cited reports of long-term crack users in Nottingham who were turning to heroin for self-medication, but who still use crack from time to time as their treat. Mordue also referred to a number of these issues:

Many of these people are not just using heroin — many of them are using prescribed medication as well, such as diazepam and temazepam ... We also find a lot of people are using heroin these days after using cocaine or amphetamines.(84)

The proponents of the proposed licit heroin trial for the ACT are aware of polydrug activities but they have not advocated the prescribing of anything new, other than diacetylmorphine. The issue of polydrug use may impact on the considerations as to who is accepted onto the program, but it is unlikely that this issue will create any new concerns for law enforcement as far as the proposed trial is concerned. The future issues may be whether Australia will see a need to consider the use of other drugs which are presently prohibited, such as cocaine and amphetamine, for medical purposes.

e. Conclusions

Methadone is a recognised treatment of heroin addicts, but it is invariably not their drug of choice. In many cases, people who are on a methadone program sell that product on the black market and/or continue to use heroin and other drugs as well. Methadone does have a positive impact on criminality and crime rates but there are still people who become addicted to it and die from it.

The indications are that the controlled prescribing of diamorphine to heroin addicts will also have a positive outcome in relation to the criminality of those individuals who are admitted to the program. It could be assumed, based on the methadone experience and by extrapolating the results of reduced criminality, that the scale of the program would dictate whether any impact was made on the crime rate.

Diamorphine prescribing should not be viewed in isolation, nor should it be viewed as opposition to methadone or other alternative treatment programs. The message is clear from this research that diamorphine should complement existing programs and that the success will largely depend on accurate assessment of the needs of the individual addict.

It is suggested that mortality rates should be given far greater importance and are worthy of more research when evaluating the success of treatment programs. Finally, the issue of polydrug use must be 'flagged' as a factor to be addressed when new initiatives are being considered and implemented.