Friday, June 14, 2013

If Heroin Were Legal: Part I

If Heroin Were Legal: Part I


One of the goals of many drug law reformers is to legalize – that is, remove criminal penalties for -- the manufacture, distribution, and possession of heroin.  Likewise, one of the often expressed fears of Drug Warriors is that heroin will be legalized.  These conflicting views raise the question: what would happen if heroin were legal?  The answer is two-fold.  First, the changes would be very small.  Second, almost all of those changes would be beneficial.

Answering this question requires looking at five different aspects: the drugs, the users, the supply business, regulation and control, and law enforcement.  Part I of this essay will examine the drugs and the users, and Part II will look at the other three issues.

The Drug:  Heroin is not a unique drug; in fact it is not even unusual.  It is a member of the group known as “opiates”, derived from the opium alkaloids, morphine, codeine, and thebaine.  This group, in addition to morphine and heroin, includes oxycodone and hydrocodone.  The last two are the basis of most modern prescription painkillers, including OxyCotin, Vicodin, and Percoset.  The opiates are closely related to the opioids, synthetic compounds designed to act like the opiates, which include fentanyl, methadone[1], Dilaudid, and Dilantin.  The body treats these drugs as virtually interchangeable.  Habitual users move easily among those drugs, substituting one for another.  Experiments at the Federal Narcotic Farm showed that even the most experienced users could not distinguish between shots of heroin and morphine.  In fact, the body converts heroin (diacetyl morphine) back into morphine in order for it to be effective.

The opiates and opioids together comprise most of medicine’s armentarium against pain.  They are employed for everything from Vicodin for a toothache to morphine for trauma or surgery to fentanyl and OxyCotin for intractable chronic pain.  If heroin loses its legal mark of Cain, it will simply become a minor, undistinguishable part of that large group.  On the other hand, if heroin were to magically disappear tomorrow, its users would simply switch to other opiates.  Or worse, as they did when heroin and morphine almost disappeared when World War II disrupted world trade, they would change to much more dangerous and deadly drugs like alcohol or barbiturates.

Users:  Opiate users[2] can be placed in several categories: medical users, experimental or casual users, dependent users, and compulsive users.  Medical users are the largest group and, under modern medical supervision developed over the last thirty years, very rarely become problematic users.  The next largest group, but still well under ten percent of the population are the casual and experimental users.  These people will experiment with opiates out of curiosity or continue modest, occasional use for years without becoming problematic, and fewer than ten percent of them become compulsive users, or “addicts”.

Anyone using opiates regularly for more than a few days, even under medical supervision, will develop a physical dependency to the drugs.  The body will not function properly without the drug, and its absence will cause withdrawal, a condition much like a severe case of the flu, that lasts for about seven days.  It is much less severe than withdrawal from alcohol, benzodiazepines, or barbiturates, which can be fatal.  After withdrawal ends, the body returns to normal without the drug.  Much of today’s confusion about opiates stems from the 1920s, before doctors learned to distinguish between dependency and addiction.  Many medical opiate users develop dependency, but modern practice includes supervised withdrawal as part of the treatment.

Compulsive users (a term without the historical and cultural baggage that has accumulated around the more common “addict”) are those who continue to use the drug in spite of knowledge that continued use will be harmful to themselves or others and who cannot resist the impulse to use.  The number of these users is small, probably less than one million in the U. S. – less than one-third of one per cent of the population.

The popular view of a drug addict is a street derelict supporting himself by petty theft, shoplifting, car burglary, or prostitution.  However, this addict only appeared in the 1920s and is a creation of drug Prohibition, not of drug use.

Evidence before passage of the Harrison Act (1914) does not clearly distinguish between dependent users and compulsive users, but by the early 1920s, the major features of compulsive use were becoming obvious.  First, long-term opiate use has no major medical consequences; the only significant sequaliae are constipation and the risk of withdrawal if use stops.  Second, even compulsive users can maintain normal, productive lives if an adequate, regulated dose is available to them (see the earlier posting on Dr. William Halsted for an early, well-documented example).

The impressive sets of evidence support this conclusion.  For almost twenty years, the Swiss have maintained documented addicts on free heroin, with no overdose deaths and a large decrease in street crime.  In the U. S. methadone maintenance has been used since the mid-1979s with few problems, although these limited programs have been complicated by having to exist within a wider regime of blackmarket illegal drugs.  England has used heroin maintenance since the end of World War I except for an interval starting during the Thatcher regime in the 1970s.  This program has had few problems, but during the time it was suspended, all of the ills of street drugs – deaths, crime, corruption, violence – emerged only to disappear when maintenance was resumed.

One key feature of these programs is that overdose deaths have virtually disappeared among the participants.

This discussion of the drugs and their users has set the stage.  Part II will examine the effects of legalization on the supply business, regulation and control, and law enforcement.

[1] Methadone was developed in Germany in the 1930s where the government feared that a war would prevent the importation of morphine for both civilian and military use.
[2] As the preceding section of drugs demonstrates, limiting the discussion to only heroin users would be misleading, or even mistaken.

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