Dan Gardner is the New York Times best-selling author of Risk, Future Babble, Superforecasting (co-authored with Philip E. Tetlock), and How Big Things Get Done (co-authored with Bent Flyvbjerg). His books have been published in 26 countries and 20 languages. Prior to becoming an author, Gardner was an award-winning investigative journalist. More >

The Hidden History of Heroin Treatment

(originally published in the Ottawa Citizen, 2004)


"I have a little bit more money now and it's fun to buy a pair of shoes or buy a sweater or a book. I love reading. Very soon I'm going to get a computer." Marion claps her hands and bounces in her seat, looking less like the thoughtful 44-year-old she is than a kid at Christmas.

She catches herself and smiles. "For other people, these are little things. Normal, daily things. But for me, it's heaven."

Marion has been a heroin addict for more than 20 years, a fact that once dominated every waking moment of her existence. "You get up. You're sick. What do I have to do get some money? You start to steal. You sell it. You buy your stuff." When the drugs are gone, the cycle starts all over again. "Around and around and around. You see yourself going down and down. It's horrible."

Marion has slept on the streets. She has been raped and robbed, arrested and jailed. Her body has been emaciated, her veins so ravaged she had to shoot heroin into her neck and groin.

But that is the past. Now she is almost giddy with optimism. When she gets her computer, she says, she is going to volunteer for an addicts' newsletter and use that experience to go after a paid job. She has an apartment. She is growing close to family members who had long ago pulled away. Her health has improved so dramatically she says, "I'm overweight. Well, I feel overweight because for years I was so thin."

Marion doesn't owe her new life to some miraculous cure. The "cures" have always failed her. She quit heroin cold turkey "10 times, 20 times," she says. Twice she went into a residential treatment clinic where she received intensive support for a total of three years. "It didn't help. I kept coming back."

What finally turned everything around for Marion is heroin. Free heroin.

Marion is a patient at the MSU, a little medical clinic on a side street in central Amsterdam. Twice a day at the clinic, nurses hand Marion a dose of methadone -- an artificial opiate chemically related to heroin that has been a standard method of treating heroin addiction for decades. But Marion also gets a dose of pharmaceutical quality diacetylmorphine, better known as heroin. She takes the drugs in the clinic, waits a few minutes, waves and walks out the door. The whole process involves little more fuss than a diabetic stopping by to take insulin.

Like most veteran addicts, Marion has developed an extreme tolerance for heroin that makes it almost impossible for her to get high but she still has to take the drug to quell cravings and stave off the flu-like symptoms of withdrawal.

"Now I have my two portions. Then for the rest of the day, I'm not sick anymore. I don't have to worry about money or stealing. I can do normal things." For the first time in decades, she is free to do something other than hustle and that freedom "is the difference between night and day."

Free junk for junkies: To most, it's a bizarre idea. Heroin is a curse, an evil blight. Why would anyone give its victims the very drug that is destroying them?

That's certainly what Marion's family thought. "In the beginning, it was, 'What? Is the government crazy?' " But the positive effects the program has had on Marion are unmistakable. "Now they really see a change," she says, and her family has decided it isn't such a bizarre idea.

Many others have also been convinced. In 2002, a committee of Canada's House of Commons recommended a trial project in this country similar to one in Holland. A team of scientists is preparing to do just that. If the trial is approved by the federal government -- final sign-off is expected soon -- the North American Opiate Medications Initiative will see pharmaceutical heroin prescribed to 210 addicts in Toronto, Montreal and Vancouver. The project is expected to begin this fall.

Radical as this might seem, Canada would only be following an international trend. Conservative Switzerland set up the first modern experiment with heroin prescription in the mid-1990s, producing results so satisfying the Swiss expanded the program and made it a permanent facet of health care. Holland followed with a more rigorous study that ended in 2001 -- again producing positive outcomes and government approval to continue the research. Germany, Spain, Italy and Australia have planned or launched their own projects. The United Kingdom is working on a scheme to greatly expand the prescription of heroin by individual doctors, even general practitioners.

Whether courageous or outrageous, the idea of prescribing illicit drugs to addicts has spread with astonishing speed, leading the media and the public to assume it's a revolutionary new idea. It's not. The ongoing prescription of drugs such as heroin to addicts -- or "maintenance" as the practice is often called -- is actually a very old medical technique that was dropped in North America when drugs were criminalized early in the 20th century. In Britain, maintenance survived criminalization and remained standard practice until the late 1960s.

The story of how this medical technique met its demise is the story of how law enforcement snatched the issue of drugs away from medicine, turning what had been a health issue into a crime problem. It's the story of how the cops beat the doctors.

For decades, it seemed the story ended there. But the explosive return of heroin prescription -- along with the spread of "harm reduction" measures such as needle exchange and safe injection sites -- suggests that medicine is rapidly taking back control of drug policy. The doctors are fighting back.

With his bright blue eyes, soul patch and a low-key voice that would do well on late-night FM radio, Dr. Wouter Barends hardly comes across as a dangerous revolutionary. A beatnik, maybe, but not a bomb-throwing radical. But some consider the Dutch doctors' work so subversive and dangerous it has been denounced even from the lofty pulpits of the United Nations and the White House.

"We are looking at the older addicts as chronic patients," Dr. Barends says. "I compare it to schizophrenia, for instance. It starts at a young age, some people recover, but for the majority it becomes chronic. Where it is chronic, people can lead a pretty normal life with medication and care. It's about the same situation with addicts. They are sick people. They are chronic patients. They need medication and care and then they can lead a reasonable life."

The medication Dr. Barends has in mind is heroin. Many addicts can be helped off drugs, he says, but some can't. "Then we come to the situation where we say we'll provide care for these people. Not a cure, but care."

Dr. Barends, an addiction specialist for 20 years, is senior public health doctor with Amsterdam's public health department. From a tiny office, he runs the MSU where patients like Marion get free daily doses of the drug that has terrified much of the western world for 90 years.

Opposition to clinics such as Dr. Barends' has been fearsome. John Walters, the White House's top anti-drug official, wrote in the Wall Street Journal that patients at these clinics, far from being "productive citizens," are "demoralized zombies seeking a daily fix."

When I read Walters' words to Dr. Barends, he jumps to his feet and takes me down the hall. He points through the window of a meeting room where a perfectly ordinary woman in her late 30s talks with a counsellor. "Does that look like a zombie to you?" he asks, grinning.

Heroin use is an odd thing. Most people who take the drug do so for a short time, or sporadically, and never become addicted. Of those who get hooked, most stop using the drug without any formal treatment within a few years. Of the remainder, most can ultimately be helped off with treatment or at least be stabilized with regular doses of heroin's chemical cousin, methadone.

Just a small fraction of users ultimately falls into the classic profile of a broken-down junkie whose addiction keeps a fierce grip as years and decades crawl by. Unfortunately, that fraction tends to be made up of the addicts who are most disturbed, damaged and alienated. They tend also to be the heaviest users of heroin and the likeliest to commit crimes to pay for their drugs. They are the wretched of the inner cities, the spectres on street corners, the junkies who populate the ghettoes, prisons and morgues.

In Amsterdam, there are roughly 5,000 addicts. Thanks to Holland's generous social welfare system and extensive treatment services, the majority are "in pretty stable conditions," says Dr. Barends. Most take prescribed methadone or other treatments. They have housing, decent health care, and regular contact with officials -- a key reason why Holland has one of the lowest rates of drug-related deaths in the western world.

Only about 10 per cent of Amsterdam's addicts live in more chaotic circumstances: hustling, often homeless, living at the extreme margins of society. These addicts have repeatedly fallen through the cracks of treatment and social services. They are the last-chancers who become Dr. Barends' patients.

In 1998, the Dutch government opened the first maintenance clinics in Amsterdam and Rotterdam. Others opened later in four more cities. About 600 addicts are currently enrolled in the whole country, 150 in Amsterdam, although that's not enough to meet the need. "We need places for about 400 people still," says Dr. Barends.

For the first three years, the program operated as a carefully constructed experiment. Eligible patients were randomly assigned either to a group that received methadone only or another that got methadone and heroin. Both groups were also given medical care and counselling.

On entering the program, patients sat through a battery of interviews about their lives and behaviour. Every two months, a team from outside the program conducted new interviews. A central committee collected and reviewed the results.

Patients were evaluated in four categories: physical health, psychological health, contact with non-drug users, and crime. To be counted as a "responder" -- a success -- a patient had to show at least a 40-per-cent improvement in one category, no increase in drug use, and no decline in any category.

The results were unequivocal. In the group given methadone only, "about 20 per cent were responders," says Dr. Barends. But in the heroin group, "55 per cent of people were responders." Of the biggest success stories -- patients who showed major improvements in two or more categories -- virtually all were from the heroin group.

A sub-study looked at what happened when the heroin -- but not the methadone -- was cut off. Within two months, 80 per cent of responding patients lost all the gains they had made. (The clinics put these patients back on heroin maintenance, Dr. Barends says, because "if you have a good treatment it's not ethical to stop it.")

Guido Vandervet was among those placed in the heroin group, a rare bit of luck in the life of the 42-year-old junkie. More than two decades spent scrambling to feed his addictions to heroin and cocaine have left his face drawn and his body thin and haggard. Still, he's looking better than he did in the past. At the lowest point, he says, "I was 45 kilos. I was near to death. I didn't eat at all. I was so crazy I lived in a closet in my house. I was convinced the police were under the couch."

After Guido started getting heroin from the MSU and gave up the relentless hunt for money and drugs, his weight shot up to 70 kilograms. "I even got my veins back," he laughs.

With his new free time, Guido works on a computer at a drop-in centre for addicts in Central Amsterdam. When the MSU made a video about the program, Guido produced the graphics for the introduction. "It was an animation of a syringe and things like that. And I got good money for that." His income these days comes from odd jobs and welfare. He has finally put petty crime behind him, he says.

A few in the program are doing even better. "Four of them got a steady job doing garbage collection," Guido says. "And they wanted to get a driver's licence really bad. But you have to be clean. You can't smoke drugs if you're behind the wheel of a truck. So they quit with everything. And from the four, only one got fired. And they're working there already for three years now."

Swiss doctors reported similar results when they experimented with heroin maintenance in 1994. In the first two-year phase of the project, patients showed major improvements in physical and mental health; homelessness dropped to one per cent from 12 per cent ; permanent employment jumped to 32 per cent from 14 per cent. Within 18 months of starting treatment, the percentage of addicts relying on crime for income plummeted to 10 per cent from 70 per cent.

The Swiss also found that while some addicts will continue taking prescribed heroin for years, most eventually move on after they get some order and stability in their lives. Of the addicts first enrolled in 1994, just one-third were still getting heroin in 2000. Of those who moved on, more than a third switched to methadone treatment, while one in five gave up drugs altogether.

Swiss researchers also calculated that the cost savings resulting from reduced crime and addicts' improved health meant the program actually saved tax dollars. The Swiss government, satisfied that heroin maintenance works, made it a permanent feature of the health-care system.

But critics complained, correctly, that the design of the Swiss study was not up to the toughest scientific standards. Hardliners in the U.S. government and United Nations dismissed the results.

Knowing this, the scientists who created the Dutch study designed it to avoid the flaws in the Swiss research. "And it basically confirmed what the Swiss had found," says Dr. Martin Schechter, an AIDS researcher and the chair of epidemiology at the University of British Columbia. "So the combination of the two studies is much more positive."

Encouraged by results in Europe, Dr. Schechter and a group of colleagues want to try the same in Canada. The North American Opiate Medications Initiative (NAOMI) will prescribe heroin through clinics in Toronto, Montreal and Vancouver.

"The core of the study is that about 210 people will be assigned to the medical heroin arm and 210 people will be assigned to the methadone arm. These people have to be chronic heroin addicts, that means at least five years of addiction. They have to have tried the best therapy at least twice in the past. And they have to be currently using heroin, which means obviously that the methadone in the past was not ultimately successful."

In November, 2002, a House of Commons committee recommended the NAOMI study go ahead. Only the Canadian Alliance members of the committee dissented. "We're supposed to find a strategy to combat illicit drug use and I get very frustrated when I see white flags waving all over the place and people in retreat mode," says Kevin Sorenson, one of the dissenting MPs. Instead of a study on heroin maintenance, the Alliance called for "a pilot project to develop detox and rehabilitation centres."

Dr. Schechter thinks the critics are fooling themselves. Research on treating heroin addiction has been going on practically since heroin was invented over a century ago. And detox and rehabilitation centres have existed across the country for decades, along with methadone programs.

"We have to accept the reality," Dr. Schechter says. "There is a subset of people with heroin addiction who repeatedly are not successful" in treatment. "Those people, although they represent a minority of people with heroin addiction, probably contribute a large proportion of the public disorder and criminal problems associated with addiction. It's very important that we try to reach out with new ways of getting these people into some form of therapy."

But there seems to be more to Sorenson's opposition to heroin maintenance than a simple disagreement about what works. It appears in his response to the common argument that heroin maintenance is no different than giving insulin injections to diabetics. Sorenson is offended by that analogy. "It's not just like diabetes. This is a self-inflicted disease. What are you telling people?"

Much as Dr. Schechter and other researchers would like to deal with addiction as a matter of science and medicine, many feel it is also a moral issue. Illicit drugs are inherently evil, so giving them to addicts is wrong no matter what the practical consequences. What's more, drug possession is a crime, and addicts are criminals who got into their sorry state by breaking the law. The only help they should be given is to quit the junk and stop breaking the law. Anything else would be coddling the guilty.

Here in 2004, it's easy to think that moral condemnation of addicts is old-fashioned while a non-judgmental attitude is modern. It's also easy to assume that heroin maintenance is a bold new idea, unlike the old, rigid insistence on abstinence. But history confounds easy assumptions.

In the 19th century, all drugs were legal and readily available. Drug addiction was not uncommon, though it was rarely the result of the recreational use of drugs. Rather it was usually caused by the excessive use of opium and morphine (and later heroin) in medical care. Self-prescribing doctors often became hooked. So did soldiers: After the Civil War, Americans called addiction "the army disease."

Just as the origins of addiction were different, so were the consequences. Because drugs were legal, they were cheap. An addict didn't have to bankrupt himself or enter a criminal subculture to maintain a habit and so addiction rarely led to a life in ghettoes and gutters. On the contrary, the Victorian stereotype of an addict was a bored, middle-class housewife.

And addiction itself was generally not considered shameful. What mattered was how the addict behaved. The addict who revelled in selfish, destructive, pleasure-seeking excess was contemptible. But the addict who worked hard and did all that was expected of a good bourgeois citizen was just as respectable as any other person. In the 1870s, Eduard Levinstein, a Berlin physician and pioneering addictions researcher, distinguished between the two, praising the addict who works diligently at his "art and profession" and "fulfils his duties to his government, his family, and his fellow citizens in an irreproachable manner."

These attitudes shaped how doctors treated addiction. Much research into breaking addiction was done and many doctors struggled to get their patients off drugs. But doctors also knew that a regular, low-level dose of morphine or heroin could keep away the sickness of withdrawal with little or no impairment of the patient's ability to lead a productive life. When quitting proved too demanding, doctors gave their patients maintenance doses.

Examples of successful Victorian junkies abound, but none rivals William Stewart Halsted. Physician, co-founder of the Johns Hopkins Hospital, and creator of so many modern surgical techniques that he is known today as the "father of American surgery," Halsted was the very model of an active citizen. He was also a lifelong drug addict. First he was hooked on cocaine but he replaced that with daily morphine injections -- a regimen that had so little effect on the surgeon that his addiction remained known only to a very few friends until decades after he died in 1922.

Halsted's death came at the end of an era in medicine. From the beginning of the 20th century until the 1920s, social reformers in many countries scored a series of victories in their drive to criminally prohibit alcohol, opium, morphine, heroin, prostitution, pornography, gambling, lewd theatre performances and dancehalls.

The anti-vice crusade was very much a moral reform movement and along with changes in the law it sought changes in attitude. Alcohol wasn't seen as merely risky to use. It was evil, and anyone who used it was immoral. The same was true of other drugs, although alcohol remained the focus of reformers' contempt.

At first, doctors took little notice of the new moralism, assuming that no matter what the legal status of drugs their freedom to practise as they saw fit would be untouched; some physicians were even leaders in the prohibition movement.

But the reformers, and the criminal prohibition they enacted, succeeded in changing how drugs were seen. Drugs were no longer a health issue. They were a criminal matter. Law enforcement officials became key figures in drug policy and the police naturally drew a bright line between the legal and illegal. Drugs were simply contraband, criminal, evil. The context of a drug's use was irrelevant because the law doesn't make exceptions for evil. Illegal drugs must simply be wiped out.

In 1916, the United States Justice Department declared that maintenance was not a legitimate medical practise and therefore was illegal under the Harrison Narcotics Act of 1914. Doctors were furious and loudly protested, but to no avail.

The Justice Department was adamant, in part because the lawmen believed a new solution for opiate addiction had been developed: An American insurance salesman had convinced top U.S. officials that his tortuous five-day regimen involving belladonna, castor oil and strychnine could cure any addiction. Most physicians thought this was nonsense -- one critic dismissed the alleged cure as "diarrhea, delirium, and damnation." Only years later did government officials acknowledge the cure was a fraud, and by then, maintenance was dead and buried.

In 1919, the U.S. Supreme Court agreed with the Justice Department, in a 5-4 decision, that maintenance was not a legitimate medical practice. The court didn't bother to say why it ruled as it did. To call maintenance medical treatment, the majority declared, is "so plain a perversion of meaning that no discussion of the subject is required."

By 1920, as historian David Musto wrote in The American Disease, "advocacy of maintenance was repressed as sternly as socialism." Doctors and pharmacists were arrested. Clinics doing the same work that the Swiss and Dutch would experiment with 70 years later, with the same results, were raided and shut down. A total ban on heroin in medicine followed.

Desperate addicts looked elsewhere for drugs and a criminal black market in narcotics blossomed. The criminal dealer "finds himself in clover," lamented the Illinois Medical Journal in 1926, while "the doctor who needs narcotics used in reason to cure and allay human misery finds himself in a pit of trouble." Within a decade of the criminalization of drugs, maintenance had vanished from the United States and was soon forgotten.

In Britain, everything was different. Unlike American physicians, British doctors were centrally licensed and represented by a single, powerful professional organization -- the British Medical Association -- empowered to discipline members for bad practice. When drugs were permanently criminalized in 1920 (a result of a clause in the Treaty of Versailles, not any domestic problem with drugs) British doctors insisted that Britain not use the American model. A leading physician warned a Home Office committee that the "chief danger" of the American law "was that attention was apt to be concentrated on the drug itself rather than upon the patient -- upon the legal aspect rather than upon the medical aspect."

Another called the American abolition of maintenance "barbarous and inhumane." Doctors must be allowed to treat patients as they and their professional association saw fit. The police should have nothing to say about it.

The doctors got their way. A 1924 report of the Home Office endorsed what was to become known as the "British system." Where a physician had made "every effort" to get the patient off drugs but had found that the treatment failed and the patient was incapable of "leading a useful and fairly normal life," the physician could prescribe a regular, stable dose of the drug. For the next 45 years, maintenance remained an option open to all British physicians, including general practitioners.

Most maintenance prescriptions were for heroin or morphine, but doctors occasionally prescribed marijuana and cocaine. In one documented case, a physician introduced to cocaine in 1900 "was still receiving about 500 milligrams daily at his death aged almost one hundred," writes historian Richard Davenport-Hines.

Like the United States and Britain, Canada faced the maintenance question when it, too, criminalized drugs. At the time, Canada was a loyal son of the British Empire but still this country chose to follow the American model -- for reasons that had little to do with principles or evidence and much to do with institutional power.

"In 1920," wrote the authors of Panic and Indifference, a history of Canada's drug laws, "the Canadian Medical Association was struggling to recover from the near-bankruptcy it experienced during the war years of 1914-18." And unlike the British Medical Association, the CMA didn't have the power to monitor and discipline wayward members, who belonged to the new, fragile and disorganized provincial associations.

Into this power vacuum stepped the RCMP. The Mounties had been formed to bring order to the wild North West, which had been accomplished by the time of the First World War. In 1917, the force was relieved of its duties in the Prairie provinces. The remaining 300 officers feared they would be disbanded if they didn't find some new reason for existing.

At exactly this perilous moment, laws banning alcohol and other drugs were popping up all over Canada. The Mounties seized the lifeline.

In the turf wars that followed, the disorganized doctors were brushed aside and the RCMP quickly took control of Canadian drug policy. As in the United States, maintenance and other medical practices that blurred the line between legal and illegal were wiped out.

Instead, the line was sharpened: Drugs became "evil" and those involved with them were, in the words of the RCMP commissioner, "the peculiarly loathsome dregs of humanity." The only acceptable approach was tough enforcement and stern punishment. The cops' victory over the doctors was total.

Only three decades later, in the early 1950s, did the issue surface again. Canadians panicked over stories of a heroin epidemic centred, then as now, in Vancouver. Whether there ever really was a surge in use is debatable, since the only evidence seems to be scary newspaper stories and the excited claims of police and politicians. Still, the fear was real. And so was the debate that followed.

In 1952, a Vancouver committee chaired by Dr. Lawrence Ranta concluded, "North American efforts at control have been spectacularly ineffective in reducing drug addiction, drug traffickers, and the thieving and moral degradation that supports the illegal drug trade."

The committee demanded that addiction be treated as a disease, not a crime, and addicts seen as patients, not criminals. In particular, the committee recommended Canada reject the American model and adopt a heroin maintenance program similar to the British system.

In 1955, a Senate committee came to the opposite conclusion. The British system wouldn't work in Canada, the committee insisted, because Britain had just a few hundred addicts compared to Canada's 3,200, so "the situation there is not comparable to that of Canada."

The senators were instead quite taken by the testimony of Harry Anslinger, the top American drug official who claimed a clear correlation between the severity of punishments and the amount of drug use. Tougher sentences were needed across the board, the senators concluded. The committee also recommended addicts be forced into treatment in special facilities -- "drug farms" similar to those that had operated in the United States since the 1930s, with dreadful results.

The senators apparently didn't notice that the British situation blatantly contradicted Anslinger's thesis that less punitive laws caused more use. Nor did they think it strange that the United States, which had recently toughened its already severe sentences, had by far the highest rates of drug use in the western world -- another obvious contradiction of the Anslinger argument.

Finally, in 1961, the government made its decision: It rejected the British system and further entrenched the American model. The new Narcotic Control Act created a mandatory minimum sentence of seven years for importing heroin, marijuana or other drugs. The maximum punishment for selling drugs was raised to 25 years from 14. Addicts caught in possession of drugs could be given an indefinite sentence in a specialized treatment facility, meaning they would only be released after they had been "cured" -- in the case of first offenders, the indefinite sentence was limited to 10 years.

The new act accomplished nothing. Very shortly after the law passed, marijuana use and trafficking exploded. (The year the Senate committee reported, 1955, there were eight convictions for marijuana possession; in 1961, there were 17; in 1970, there were 5,399; in 1972, 10,695.) The use and trafficking of heroin and other drugs also rose rapidly. Countless draconian punishments were meted out, but contrary to all expectations, they had no effect on the rising flood of drugs, addiction, crime and misery.

In 1969, a bewildered government created the LeDain Commission to investigate Canada's drug policies. Although the commission is most famous for recommending the legalization of marijuana possession, it also called for a heroin maintenance trial project. On that point too, the commission was ignored.

How might things have been different if the government had followed the British lead? That will never be known, of course, but an intriguing hint lies in an obscure survey of 25 Canadian addicts living in Britain in the 1960s. All the addicts had been hooked on junk for many years in Canada before moving overseas. And all had received heroin maintenance in Britain.

The survey found the move from Canada's punitive approach to the British system produced startling changes. In Canada, only two of those surveyed said they worked steadily while addicted. In Britain, 13 had full-time jobs and four worked part-time; six of the full-time employees had been working at the same job for three or more years.

In Canada, 20 of those surveyed "moved about often to avoid detection and arrest." In Britain, 10 had been living at the same residence for two or more years when they were interviewed and eight had been in one place for one to two years. None was homeless.

In Canada, the respondents' average number of criminal convictions was 7.3 and they had spent an average of 6.7 years in prison; only two of the 25 respondents had never been convicted of a crime. Many of these offences were drug crimes, including possession and dealing, but by far the most common crime was theft. In Britain, 12 of the respondents had never been convicted of a crime, while five had been convicted once.

These results, compelling as they are, likely understate the impact of heroin maintenance because the Canadians involved had already spent years in a criminalized heroin subculture. For most addicts in that environment, lying, cheating and stealing become second nature. And old habits die hard.

British addicts who got heroin maintenance from the beginning of their addiction were never forced to enter a criminal subculture or learn criminal habits. As a result, they were often very ordinary people, says Cindy Fazey, formerly a high-ranking official in the United Nations Drug Control Program and now professor of drug policy at the University of Liverpool.

In 1966, while working on her PhD, Fazey worked at a heroin maintenance clinic in Birmingham. "It was just a normal part of their lives. Just as a diabetic needs to inject, so a drug addict does. They were holding down jobs. There was an architect. A computer programmer. The ones with disorganized lives tended to be disorganized anyway and actually the prescriptions added some organization and stability."

The police, too, treated addicts as sick people, not criminals. "Addicts would not be hassled as long as they were straight and didn't deal," says Fazey. "The relationship between the addicts and the police was extremely good. There was one occasion where a couple were chucked out of their lodgings on a Sunday morning because the landlord found out they were addicts. They immediately phoned the drug squad and said, `Help!' And the drug squad came and told the landlord they were OK, they are under treatment, they were not a problem." They got the apartment back.

A tiny portion of prescribed drugs was sold illegally into a "grey market" but there was virtually no drug smuggling in Britain and no "black market at all," says Fazey. With addicts receiving their drugs from doctors, there simply wasn't enough demand to boost the price of street drugs and generate the profits that lure criminals into trafficking. Hard as it may be to imagine today, impure, untested, illegal heroin simply could not be found on British streets.

Nor did maintenance result in doctor's offices spilling over with addicts. For decades, the number of British maintenance patients stood between 300 and 600.

With tiny numbers of addicts living relatively normal lives, and no criminal black market at all, Britain offered an alternative to the punitive approach that had dominated North America since the 1920s. Throughout the 1950s, American and Canadian reformers constantly pointed to the superior results in Britain, to no avail. The criminal justice approach only got stronger.

Worse, the British system itself came under attack. In the mid-1960s, British baby boomers turned to heroin and other drugs in unprecedented numbers. The same trend swept many western countries regardless of their drug policies but many British politicians and newspapers claimed it was entirely the result of a few doctors in London who seemed to be handing over prescriptions to anyone who asked.

At the same time, pressure from the U.S. government and a growing acceptance of the American view that heroin was inherently evil put the whole system in jeopardy.

A new act in 1968, and another in 1971, effectively shut down the British system. "It stopped GPs from prescribing," says Fazey. "Doctors could only prescribe if they had a licence from the Home Office. And that licence was only given, with one or two exceptions, to consulting psychiatrists who were in teaching hospitals and had clinics for alcoholics."

Many of the psychiatrists, with little or no experience with opiate addictions, "had gone to a rather moral attitude of, why should we indulge you?" Fazey says. As in the United States, abstinence became the overriding goal and by the late 1970s a minuscule fraction of addicts was being prescribed heroin.

The fall of the British system brought the rise of the black market. In 1969, Fazey was working in the Home Office when the head of the drugs branch "called me into his office and said hey, look at this. He opened his drawer and there's this little plastic bag. And that was the first time we'd seen illegal heroin."

By 1984, Britain had as many as 75,000 addicts -- many of them unemployed, homeless, unhealthy and living by petty crime. Today, Britain has 240,000 addicts and the black market is bigger and more violent than ever. The Blair government, which has generally taken a hard line on drugs, has nonetheless announced plans to restore much of the old British system.

With maintenance being rediscovered in country after country, hardliners in the UN and the White House are doing their best to discredit the idea. John Walters, the U.S. drug czar, attacked the British system in the Wall Street Journal last year.

"When British physicians were allowed to prescribe heroin to certain addicts, the number skyrocketed," Walters wrote. "From 68 British addicts in the program in 1960, the problem exploded to an estimated 20,000 heroin users in London alone by 1982."

This is deeply deceptive, says Fazey. Not only had the British system been in place for decades before 1960 without any increase in addiction, it was effectively dead "by about 1972."

American attacks on heroin maintenance are particularly ironic given that it was the United States that pioneered another successful form of maintenance. Methadone is a synthetic opiate chemically related to heroin. It is just as addictive as heroin but it doesn't cause a high if used as directed by a physician. And unlike heroin, it can be taken orally and lasts for a full day. American researchers realized that makes it ideal for maintenance and in the 1960s they showed that many heroin addicts could be stabilized and lead a normal life while on methadone. In the 1970s, methadone became standard treatment in the United States, Canada and elsewhere.

But methadone maintenance was controversial at first for exactly the same reason heroin maintenance is now: It involves giving an addict a steady supply of the drug to which he is addicted. So why is methadone maintenance accepted today as legitimate treatment while heroin maintenance is hotly controversial? Dr. Martin Schechter insists it has nothing to do with the properties of the drugs themselves. "They're both opiates," he says. "They're both highly addictive."

The difference is purely image, Dr. Schechter says. Methadone is seen as just a drug, a medicine, something that can be used constructively under a doctor's supervision. So are the others in the opiate family. "Demerol, morphine, and Tylenol 3 with codeine are drugs. But heroin is `evil.' That doesn't make sense."

The Swiss broke this taboo when they experimented with heroin as medicine. The Dutch followed. Canada, Britain and others are set to do the same. With time and continued success, the physicians behind the heroin maintenance projects may restore a valuable old medical technique.

And they may do more than that. They may also advance the idea that drug policy should not be about criminalizing users, demonizing drugs and trying, futilely, to wipe out the drug trade. Instead, drugs would be dealt with strictly as a health issue. Old taboos would be junked. The police would cease to lead the discussion. Whatever could be proved to promote human well-being would be done, no matter how odd it may sound at first -- even giving junk to junkies.

Dr. Schechter thinks this process is already far along. "In Canada, we are discussing trying things, like safe injection sites, like medically prescribed heroin trials, that we would never have dreamed of talking about five or 10 years ago. And I will predict this will continue, and we will eventually -- I don't know when, but the issue of decriminalization and the conversion of drugs into a public health and medical situation will be on the front burner in this country in the future. That debate will occur. There is just no escaping it."

The doctors are fighting back.

Marion, Guido and the other heroin maintenance patients at the Amsterdam MSU have their own struggle now that they no longer have to spend every waking moment hustling for heroin: How to live a normal life.

As a junkie living at the margins of society, Marion says, "you also get addicted to stealing or whatever. If I see something expensive I still have to watch myself that I don't, by reflex, put it in my pocket. It's so ingrained."

Not only do old habits have to go, new ways to fill the day have to be found. New patients in the program "don't know what to do with their time," Guido says. "And some use more coke than they used to. Or some start using coke because they're used to going to the dealer. But after half a year, they settle down. They start doing normal things. Get a job. Contact the family again."

For those who have been addicted for decades, it truly means starting over. "I have to relearn things I learned as a child," Marion says. "It's the little things. Getting up on time. Being on time at your job. Taking care that you eat. Even things as simple as looking somebody straight in the eye. I still think that people see a junkie."

When Marion describes the challenges she faces, she doesn't sound daunted so much as eager, even excited. "I have hope again," she says, her eyes wide with amazement. "If I have a computer, maybe I can fit my way back into society."

The computer again. She can't stop talking about the computer. Just like a kid at Christmas.