Wednesday, June 16, 2004

Heroin: Hazy logic dictates a painful prohibition

Between moments of pungent humour, The Barbarian Invasions is a confronting movie. Facing a painful death to cancer, Remy, a self-described "socialist, hedonist lecher", accepts Montreal's crumbling, cramped public health system as his left-wing fate.

Until his estranged son, a rich investment banker - a "capitalist, ambitious prude", says Remy - jets in from London to make his father's last days more comfortable.

Sebastien learns from a doctor friend that heroin will be "800 per cent more powerful" than morphine - the standard fare dispensed by doctors to cancer patients. And so he seeks out the dealers and users necessary to secure heroin for Remy.

When it comes to helping those with painful terminal illness, the story will be sadly familiar to many in Australia. My father died of cancer, like more than 35,000 Australians each year. And like many others, he died in pain. It is hard to know what hurt him most. The pain that grew in his spine and, in the end, seemed to rack his entire body. The pain that he would never see his family again. Or the knowledge that we would watch his painful demise.

Like Remy, doctors only offered my father morphine to relieve his pain. Different sorts with different names, my family and I administered it to him in ever increasing doses, doubling, sometimes tripling what doctors advised. Morphine chased his pain. And sometimes caught it. When it didn't, it was dreadful. If minutes were like hours for us, I cannot imagine how it was for him. I know one thing: he needed more than what doctors offered him. Watching The Barbarian Invasions, I felt I had failed him for not traipsing the streets for heroin. If it could have relieved his physical pain or stoic mental suffering, that would have been a godsend.

Australia has an irrational history when it comes to using heroin for those dying in pain. In May 1953, the Menzies government prohibited its importation after pressure from the World Health Organisation, in turn under pressure from the US, where a burgeoning drug problem was emerging. Yet in Australia there was no drug problem to speak of; instead heroin was used to manage serious pain, especially for the terminally ill.

The ban went ahead despite objections from the director-general of health in NSW that "heroin ... is quite effectively controlled in this state and ... I see no justification to enforce absolute prohibition". And despite similar protests by the Royal Australasian College of Physicians and the predecessor to the Australian Medical Association, then the Australian Federal Council of the British Medical Association.

Ever since, heroin has been lost to the moral battlefield of illicit drugs.

Once banned, it was a drug with no legitimate role, one that junkies use and drug criminals deal in. What strikes me as more criminal is that, in 2004, the terminally ill still die in pain. Irrational responses get in the way of treating their pain. On the one hand, politicians parade their massive heroin hauls, piles of white bricks, as wins in the tough war on drugs. On the other, they help drug addicts on the street shoot up, providing them with clean needles and clean rooms. Those left out in the cold are the terminally ill.

It does not require much nuance to understand that allowing doctors to administer heroin to the dying is not a slippery slope to its legalisation. Nor will it lead to a nation of addicts. Doctors prescribe prohibited substances by the hundreds. Why is heroin different? A stubborn, unthinking abstinence lobby. That is the difference.

It does not require much compassion to understand that a fear that someone you love, dying of cancer, may become addicted to heroin is less important than ensuring they are relieved of terrible pain.

Why the irrational fear? Addiction as a moral evil has little resonance for those in pain.

It does not require much political courage to suggest that if British doctors can use heroin for those dying in pain, why shouldn't Australians facing a similar fate have the same choice? Granted, prominent doctors in both Australia and Britain point to doubts about whether heroin provides better pain relief than morphine. Nurses who have given heroin to the dying have fewer doubts. I am with the nurses. They are at the coalface of suffering.

It is true that morphine is a derivative of heroin, otherwise known as diacetyl-morphine. But heroin is more soluble, entering the body faster, absorbed quickly into fatty tissue like the brain. Heroin users talk about feeling a "rush". After that initial euphoria, heroin causes an alternately wakeful and drowsy state.

I don't want junkies determining drug policy but that they favour heroin over morphine suggests that the terminally ill might also prefer it. Euphoria is the wrong word for those dying of cancer, but if heroin can offer any kind of relief, mental or physical, why not offer it?

If we do more to ease the pain of the terminally ill, it may take much of the heat out of the euthanasia debate. That too is a good thing. In the end, Remy dies at home surrounded by those who love him most, and free from pain. My father was less fortunate. His family was there. But so was that unwelcome intruder, pain. With an ounce of common sense, compassion and political pluck, perhaps it need not have ended that way.



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