Heroin Use in the Minnetonka Area: An Outsider’s Take

By Andrew Tuttle MD

I moved to Switzerland from Minneapolis as a boy. I am a psychiatrist and have been in private practice for the last twenty years in a town near Zurich, Switzerland, where I mostly grew up and got my medical and psychiatric training. My father, Gedney Tuttle (ever heard of Gedney‘s Pickles?), lives in Orono. I witnessed first hand an exploding heroin epidemic here in Switzerland in the 70’s through the 90’s and played a small part in dealing with it. I wish to submit the following comments in reference to recent articles in “The Patch” regarding the spreading heroin-problem, in particular to:

“Community Meeting Planned to Discuss Heroin Use around Lake Minnetonka”

and

Abuse of prescription painkillers a gateway to local heroin use, they say.”

I submitted my doctoral dissertation on heroin related deaths in Switzerland in 1982. It was the time when the unimaginably horrific needle park scenes were forming. Try seeing your self, say, in the park around lake Calhoun, the park densely packed exclusively with people either selling drugs or being in various stages of injecting them - hundreds and hundreds of people, the ground ankle deep in refuse and discarded needles. I went there, I observed it, it was like being on a different planet, horrible, alienating, and very scary. Even the addicts didn‘t find it an attractive place to be – it was just a place to quickly and easily obtain and use any imaginable illicit drug, and possibly many addicts found some short sense of comfort or recognition by being amongst other addicts there.

Since then, Switzerland has developed an exemplary – although, in my opinion, still not optimal – approach to drug abuse based on the three tiers of prevention, repression, and treatment/rehabilitation. The model has attained worldwide attention and is being emulated by other countries. Repression focuses mainly on the outright criminal aspects of drug abuse: The distributors, the drug related crimes (mostly theft), but also against the formation of localized drug scenes or selling spots (making distribution harder). The needle parks are gone today and are safe to visit. The end of the line users are, if at all possible, not criminalized unless heavily involved in distribution or other criminal activities themselves (sadly often the case, to enable their own supply of heroin), but since heroin use itself does remain illegal, they can, circumventing incarceration or the imposition of crushing judicial sanctions, be sort of coerced into a supervised treatment plan, and surprisingly often successfully so. Treatment facilities collaborate with courts and law enforcement. Long-term treatment plans with methadone or buprenorphine often work well, but fail in many cases.

The thing is, if somebody has experienced and gotten use to the effect of heroin, nothing else will ever be as good: Like no other opiate, at least ten times more easily and effectively than morphine, heroin directly floods the brain and stimulates the endorphin receptors there like no other drug can (actually it should be Heroin®, an original product of Bayer Pharmaceuticals, thank you very much).

Recognizing this, Switzerland made a bold choice: Amongst other less spectacular measures, such as opening many low threshold, walk-in detox facilities, it established, at first on a trial basis, a heroin distribution center in Zurich, where heavy addicts who had failed other treatment options could obtain and administer a sterile, individually determined dose of heroin, with a sterile needle, up to three times a day. That was well over a decade ago, and after it had quickly proven to be empirically successful, more distribution centers were opened at key places all over Switzerland. There is sound medical evidence today that the plan works: The addicts are removed from the illegal distribution chain, they get healthier, some are able to work again, and some are eventually able to graduate into a detoxification and rehabilitation program, and actually make it out and become truly rehabilitated.

Another controversial measure, mainly implemented in the larger cities Zurich, Berne and Basel, was the designation of "safe rooms" for the street addicts: A locale where they could enter, obtain a free sterile needle and syringe (if using by injection), and apply their street drugs without being hassled by police or others – instead of having to remain publicly exposed in a back alley and nervously attempt to puncture a vein with a dirty needle, which then might be discarded for some child to find. Social workers staff the rooms, build relationships with the addicts and can sometimes guide them into an actual treatment plan.

It is interesting how heroin has become so cheaply available. When I graduated from medical school in 1980, the going street price for a gram of heroin (here in Zurich) was almost $200.-; today, the same amount can be obtained for $20.- or so, depending on the quality. I was surprised to hear that the quality of heroin around Hennepin county is so high – over 90% pure. Here, 30% is considered to be acceptably good. In my opinion, the high quality means there must be a very short distribution chain between producer and buyer, otherwise the heroin would be cut down (diluted with an inexpensive agent that looks like heroin, for instance talcum powder) by intermediary distributors, to increase profits. My own logic tells me that for this to be possible, poppy-fields and the production of heroin must be very close to where it is being distributed; possibly Mexico? Or – hard to imagine – within the USA?

The inexpensive price and high quality would likely make heroin much more accessible, with a much wider angle of distribution. And the purity would make it dangerously easy to overdose: It is much harder to gauge a safe dose with almost pure heroin. One consequence of the low price is that the heroin needn‘t be injected to get a maximum “bang for your buck“: It can be smoked or sniffed, a somewhat more wasteful way of using it, but ultimately no less effective, and no less addicting. The very worrisome aspect of this, is that it drastically lowers the threshold for first-time use: Many that would be deterred by having to use a needle have far fewer inhibitions to smoke or sniff heroin, often erroneously thinking that this poses a smaller risk of becoming addicted – and it very quickly induces dependence; much, much sooner than the user him/herself realizes. I‘ve heard the phrase “I have a handle on it“ so many times that it has become diagnostic of manifest addiction for me.

Since the “Swiss model“ has been implemented, there are no more open drug scenes of significance here. Heroin use and heroin addiction has gone down (in spite of low prices!), as has drug related criminality. One or the other treatment facility has shut down for lack of clientele. The incidence of HIV-infections as well as Hepatitis C has decreased, in part due to the open availability of sterile injection paraphernalia. In most areas, drug users are off the streets. People have become less worried of their children being exposed to dangerous drugs by simply sending them to school.

From here in Europe, the USA is viewed as being much too heavily lopsided on repression: On the criminal aspects of heroin use and drug use in general. Amongst health professionals dealing with addicts here the American phrase “war on drugs“ is used or referred to with sarcasm, because the approach is seen as futile. As long as there are poppy-fields that are cash crops (and they are not likely to disappear), there will be heroin: Everywhere. No matter how affluent or tightly knit a community is, heroin will reach it. It will not go away, it cannot be totally repressed. I posit that there isn‘t a single high school in Hennepin or any other County, public or private, that can safely claim to have no students using heroin. Heroin-use spreads in an epidemic pattern. A user will want someone to share with him/her and so on, and eventually it will reach even the most rural areas. And don’t think that policing measures such as urine-samples or body-searches will prevent heroin from appearing in your school or workplace: Users are phenomenally creative when it comes to concealing their use and will find ways of evading any detection measure. I have even known addicts to use pupil-dilating eye-drops to counteract the telltale pinpoint pupils.

Repression must be counterbalanced with diverse treatment modalities, where an open mind and creativity is called for, and with preventive measures that equally call for open-mindedness and creativity. Heroin addiction needs to be shifted more out of the aspect of criminality and dealt with more as a health problem and social problem, and with a more humanistic view. Instead of just chasing addicts down, they need to be reached out to and treated. Implement more diversified approaches to the problems of heroin use, and you stand a chance of containing – not eradicating, that simply won‘t happen – the spread of heroin use. On this note I would strongly concur with the Anoka County sheriff James Stuart: You absolutely have to implement a diverse spectrum of treatment options and come up with more ideas for preventive measures. Of course this means making funding available, possibly lots of it. But I promise you, in the long run it will prove to be cost effective, and will make your area a safer place for you and your children to live in.

 October 17, 2012

 Andrew Tuttle MD