Archive for November, 2010


Treatment for OIC


Treatment options for OIC

Although opioids are very effective for treating and managing pain, their use frequently results in opioid-induced constipation (OIC). Treatment options for OIC may be as simple as changing diet or as complicated as requiring several medicines and laxatives.


How can changing lifestyle factors treat OIC?

Changing lifestyle factors is usually the first recommendation that physicians make for the prevention or treatment of constipation. This includes:

  • Increasing dietary fiber
  • Increasing fluid intake
  • Increasing exercise or physical activity
  • Increasing time and privacy for toileting

Changes in lifestyle, however, may not be possible for many patients. In addition, these changes may be ineffective in treating OIC. If there is a concurrent underlying disease or medicine that is causing constipation, the disease may need to be treated separately or another treatment regimen may have to be considered.


What drugs or medicines treat OIC?

medication

OIC treatment usually requires additional medicines to be prescribed along with the opioid painkillers that are causing the constipation. Withholding the opioid treatment is ill-advised because it results in a decrease in the patient’s quality of life. Often, laxatives and/or cathartics are prescribed at the same time as the opioid painkillers so that treatment for the constipation beings immediately. A cathartic accelerates defecation, while a laxative eases defecation, usually by softening the stool; some medicines are considered to be both laxatives and cathartics.

For the treatment of OIC, doctors may prescribe:

  • Osmotic laxatives – increase the amount of water in the gut, increasing bulk and softening stools.
  • Emollient or lubricant cathartics – soften and lubricate stools.
  • Bulk cathartics – increase bulk and soften stools.
  • Stimulant cathartics – directly counteract the effect of the opioid medications by increasing intestinal motility, helping the gut to push the stools along.
  • Prostaglandins or prokinetic drugs – change the way the intestines absorb water and electrolytes, and they increase the weight and frequency of stools while reducing transit time.
  • Other medicines block the effects of opioids on the bowel to reverse opioid-induced constipation.

Although the treatments listed above are usually successful in treating OIC, sometimes a physician will recommend rectal intervention. As discussed, prophylaxis with laxatives are/or cathartics is considered usual – as some clinicians assume [constipation] to be virtually universal in patients who are prescribed opioid analgesics1.

Rectal interventions are indicated if the appropriate oral measures have been ineffective2. Rectal intervention means the following treatments:

  • Suppositories
  • Enemas (micro and larger volume)
  • Rectal irrigation (sometimes known as colonic irrigation)
  • Manual evacuation

The first choice rectal intervention for uncomplicated constipation is glycerine suppositories2. If these are ineffective, then a stimulant enema might be administered. Oral and rectal stimulant laxatives should be avoided if there is possible or proven bowel obstruction. Gentle rectal measures can sometimes be effective in emptying the rectum and lower colon. Oral softening agents are useful if the obstruction is incomplete. It should be remembered that constipation can cause bowel obstruction.

If none of the rectal laxatives above prove adequate to remove impacted faeces, rectal irrigation with normal saline can be performed3. Manual evacuation should be used as a last resort when all other methods of bowel management have been shown to be ineffective.


Combination therapy

Constipation is a known side effect of opioid analgesics and should be addressed before opioid therapy begins. As opioid-induced constipation can be severe and adversely impact quality of life and compliance with therapy, prophylaxis with laxatives is considered to be the best approach. A British Pain Society survey conducted in March 2009 showed that nearly half of GPs (44%) surveyed believe that the negative impact of such side effects is the key factor in patient non-compliance with prescribed opioid treatments.

Concurrent management on initiation of opioids frequently includes recommending certain lifestyle or dietary adjustments (as listed above) and initiating a scheduled regimen of laxatives. Laxative and cathartic therapy may be needed throughout opioid therapy and beyond. Effective management requires a composite of strategies, including behavioral and lifestyle changes (diet, activity, and fluid intake, as appropriate).

However medications used to manage opioid-induced constipation, such as laxatives, do not address the underlying opioid receptor-mediated cause of constipation and are often ineffective4.


Newer targeted treatments for opioid induced constipation

Methylnaltrexone (available as Relistor(R)) helps restore bowel function in patients who have advanced illness and receive opioids for pain relief. Methylnaltrexone is delivered via subcutaneous injection and specifically targets opioid-induced constipation. When given alongside opioid therapy, it is designed to displace the opioid from binding to peripheral receptors in the gut, decreasing the opioid’s constipating effects and inducing laxation.

Methylnaltrexone is a peripherally acting mu-opioid receptor antagonist that decreases the constipating effects of opioid pain medications in the gastrointestinal tract without diminishing their ability to relieve pain.

Methylnaltrexone blocks peripheral opioid receptors in the gut and unlike other opioid antagonists has restricted ability to cross the blood-brain barrier. As a result, it antagonizes only the peripherally located opioid receptors in the GI tract, so it’s action reverses opioid-induced constipation without precipitating withdrawal symptoms or affecting or reversing the central analgesic effects of opioids5.

Another new medication for severe pain (long-term pain that can be experienced as a result of conditions such as back pain, arthritis and osteoarthritis)6, are tablets combining prolonged release oxycodone, an opioid which treats pain, and prolonged release naloxone, a compound which counteracts the potential negative effects of the opioid on the GI function (available as TarginactTM). This novel combination has been proven to provide equivalent pain relief to oxycodone alone, whilst significantly improving bowel function7. Naloxone is an opioid receptor antagonist that, when taken orally, has negligible systemic bioavailability8 providing a full inhibitory effect on local opioid receptors in the gut – counteracting opioid-induced constipation – without impacting on the centrally acting analgesic efficacy of oxycodone.

diagram of opioids with mu-opioid receptors

* Image borrowed from Wyeth library


1. Hanks G, Cherny N, Fallon M. Symptom Management. The management of pain: Opioid Analgesic Therapy. In Oxford textbook of Palliative Medicine, 3rd Ed. Oxford University Press, 2003.
2. Cancer – a cpomprehensive clinical guide, By David L. Morris, John Henry Kearsley, Christopher John Hacon Williams
3. Oxford textbook of palliative medicine, By Derek Doyle, Geoffrey Hanks, Nathan I. Cherny, Kenneth Calman
4. Reimer K, Hopp M, Zenz M, Maier C, Holzer P, Mikus G, Bosse B, Smith K, Buschmann-Kramm C, Leyendecker P: Meeting the Challenges of Opioid-Induced Constipation in Chronic Pain Management – A Novel Approach.
Pharmacology 2009;83:10-17 (DOI: 10.1159/000165778)
5. Ho et al. 2003; Kurz and Sessler 2003; Schmidt 2001; Foss 2001
6. Severe pain, which can be adequately managed only with opioid analgesics
7. Vondrackova D, Leyendecker P, Meissner W. et al. Analgesic efficacy and safety of oxycodone in combination with naloxone as prolonged release tablets in patients with moderate to severe chronic pain.J Pain. 2008; 9(12): 1144-1154.
Meissner W, Leyendecker P, Müller-Lissner S, et al. A randomised controlled trial with prolonged-release oral oxycodone and naloxone to prevent and reverse opioid-induced constipation. Eur J Pain. 2008; doi:10.1016/j.ejpain.2008.06.012.
Simpson K, Leyendecker P, Hopp M, et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe non-cancer pain. Curr Med Res Opin. 2008; 24(12): 3503-3512.
8. Nadstawek J, Leyendecker P, Hopp M, et al. Patient assessment of a novel therapeutic approach for the treatment of severe, chronic pain. Int J Clin Pract. 2008; 62: 1159-116.

source: http://www.medicalnewstoday.com/info/oic/treatment-for-opioid-induced-constipation.php

 

Oral Naloxone Reverses Opioid-Associated Constipation

Meissner W, Schmidt U, Hartmann M, et al
Pain. 2000; 84(1):105-9

Opioid-related constipation is one of the most frequent side effects of chronic pain treatment. Enteral administration of naloxone blocks opioid action at the intestinal receptor level but has low systemic bioavailability due to marked hepatic first-pass metabolism. The aim of this study was to examine the effects of oral naloxone on opioid-associated constipation in an intraindividually controlled manner. Twenty-two chronic pain patients with oral opioid treatment and constipation were enrolled in this study. Constipation was defined as lack of laxation and/or necessity of laxative therapy in at least 3 out of 6 days. Laxation and laxative use were monitored for the first 6 days without intervention (‚control period‘). Then, oral naloxone was started and titrated individually between 3×3 to 3×12 mg/day depending on laxation and withdrawal symptoms. After the 4-day titration period, patients were observed for further 6 days (’naloxone period‘). The Wilcoxon signed rank test was used to compare number of days with laxation and laxative therapy in the two study periods. Of the 22 patients studied, five patients did not reach the ’naloxone period‘ due to death, operation, systemic opioid withdrawal symptoms, or therapy-resistant vomiting. In the 6 day ’naloxone‘ compared to the ‚control period‘, the mean number of days with laxation increased from 2.1 to 3.5 (P<0.01) and the number of days with laxative medication decreased from 6 to 3.8 (P<0.01). The mean naloxone dose in the ’naloxone period‘ was 17.5 mg/day. The mean pain intensity did not differ between these two periods. Moderate side effects of short duration were observed in four patients following naloxone single dose administrations between 6 and 20 mg, resulting in yawning, sweating, and shivering. Most of the patients reported mild or moderate abdominal propulsions and/or abdominal cramps shortly after naloxone administration. All side effects terminated after 0.5-6 h. This controlled study demonstrates that orally administered naloxone improves symptoms of opioid associated constipation and reduces laxative use. To prevent systemic withdrawal signs, therapy should be started with low doses and patients carefully monitored during titration.

 

source is: http://www.medscape.com/viewarticle/435954

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On April 3 1924, a group of American congressmen held an official hearing to consider the future of heroin. They took sworn evidence from experts, including the US surgeon general, Rupert Blue, who appeared in person to tell their committee that heroin was poisonous and caused insanity and that it was particularly likely to kill since its toxic dose was only slightly greater than its therapeutic dose.

They heard, too, from specialist doctors, such as Alexander Lambert of New York’s Bellevue hospital, who explained that „the herd instinct is obliterated by heroin, and the herd instincts are the ones which control the moral sense … Heroin makes much quicker the muscular reaction and therefore is used by criminals to inflate them, because they are not only more daring, but their muscular reflexes are quicker.“ Senior police, a prison governor and health officials all added their voices. Dr S Dana Hubbard, of the New York City health department, captured the heart of the evidence: „Heroin addicts spring from sin and crime … Society in general must protect itself from the influence of evil, and there is no greater peril than heroin.“

The congressmen had heard much of this before and now they acted decisively. They resolved to stop the manufacture and use of heroin for any purpose in the United States and to launch a worldwide campaign of prohibition to try to prevent its manufacture or use anywhere in the world. Within two months, their proposal had been passed into law with the unanimous backing of both houses of the US Congress. The war against drugs was born.

To understand this war and to understand the problems of heroin in particular, you need to grasp one core fact. In the words of Professor Arnold Trebach, the veteran specialist in the study of illicit drugs: „Virtually every ‚fact‘ testified to under oath by the medical and criminological experts in 1924 … was unsupported by any sound evidence.“ Indeed, nearly all of it is now directly and entirely contradicted by plentiful research from all over the world. The first casualty of this war was truth and yet, 77 years later, the war continues, more vigorous than ever, arguably the longest-running conflict on earth.

Drugs and fear go hand in hand. The war against drugs is frightening – but not, in reality, for the reasons which are claimed by its generals. The untold truth about this war, which has now sucked in every country in the developed world, is that it creates the very problem which it claims to solve. The entire strategy is a hoax, with the same effect as an air force which bombs its own cities instead of its enemy’s. You have to go back to the trenches of Flanders to find generals who have been so incompetent, so dishonest, so awesomely destructive towards those for whom they claim to care.

The core point is that the death and sickness and moral collapse which are associated with class A drugs are, in truth, generally the result not of the drugs themselves but of the black market on which they are sold as a result of our strategy of prohibition. In comparison, the drugs themselves are safe, and we could turn around the epidemic of illness and death and crime if only we legalised them. However, it is a contemporary heresy to say this, and so the overwhelming evidence of this war’s self-destructive futility is exiled from almost all public debate now, just as it was when those congressmen met.

Take heroin as a single example. And it’s a tough example. In medical terms, it is simply an opiate, technically known as diamorphine, which metabolises into morphine once it enters its user’s body. But, in terms of the war against drugs, it is the most frightening of all enemies. Remember all that those congressmen were told about „the great peril“. Remember the Thatcher government’s multimillion pound campaign under the slogan „Heroin screws you up“. Think of Tony Blair at the 1999 Labour party conference fulminating about the „drug menace“ or of William Hague last year calling for „a stronger, firmer, harder attack on drugs than we have ever seen before“. And now look at the evidence.

Start with the allegation that heroin damages the minds and bodies of those who use it, and consider the biggest study of opiate use ever conducted, on 861 patients at Philadelphia General hospital in the 20s. It concluded that they suffered no physical harm of any kind. Their weight, skin condition and dental health were all unaffected. „There is no evidence of change in the circulatory, hepatic, renal or endocrine functions. When it is considered that some of these subjects had been addicted for at least five years, some of them for as long as 20 years, these negative observations are highly significant.“

Check with Martindale, the standard medical reference book, which records that heroin is used for the control of severe pain in children and adults, including the frail, the elderly and women in labour. It is even injected into premature babies who are recovering from operations. Martindale records no sign of these patients being damaged or morally degraded or becoming criminally deviant or simply insane. It records instead that, so far as harm is concerned, there can be problems with nausea and constipation.

Or go back to the history of „therapeutic addicts“ who became addicted to morphine after operations and who were given a clean supply for as long as their addiction lasted. Enid Bagnold, for example, who wrote the delightful children’s novel, National Velvet, was what our politicians now would call „a junkie“, who was prescribed morphine after a hip operation and then spent 12 years injecting up to 350mg a day. Enid never – as far as history records – mugged a single person or lost her „herd instinct“, but died quietly in bed at the age of 91. Opiate addiction was once so common among soldiers in Europe and the United States who had undergone battlefield surgery that it was known as „the soldiers‘ disease“. They spent years on a legal supply of the drug – and it did them no damage.

We cannot find any medical research from any source which will support the international governmental contention that heroin harms the body or mind of its users. Nor can we find any trace of our government or the American government or any other ever presenting or referring to any credible version of any such research. On the contrary, all of the available research agrees that, so far as harm is concerned, heroin is likely to cause some nausea and possibly severe constipation and that is all. In the words of a 1965 New York study by Dr Richard Brotman: „Medical knowledge has long since laid to rest the myth that opiates observably harm the body.“ Peanut butter, cream and sugar, for example, are all far more likely to damage the health of their users.

Now, move on to the allegation that heroin kills its users. The evidence is clear: you can fatally overdose on heroin. But the evidence is equally clear, that – contrary to the claims of politicians – it is not particularly easy to do so. Opiates tend to suppress breathing, and doctors who prescribe them for pain relief take advantage of this to help patients with lung problems. But the surprising truth is that, in order to use opiates to suppress breathing to the point of death, you have to exceed the normal dose to an extreme degree. Heroin is unusually safe, because – contrary to what those US congressmen were told in 1924 – the gap between a therapeutic dose and a fatal dose is unusually wide.

Listen, for example, to Dr Teresa Tate, who has prescribed heroin and morphine for 25 years, first as a cancer doctor and now as medical adviser to Marie Curie Cancer Care. We asked her to compare heroin with paracetamol, legally available without prescription. She told us: „I think that most doctors would tell you that paracetamol is actually quite a dangerous drug when used in overdose; it has a fixed upper limit for its total dose in 24 hours and if you exceed that, perhaps doubling it, you can certainly put yourself at great risk of liver failure and of death, whereas with diamorphine, should you double the dose that you normally were taking, I think the consequence would be to be sleepy for a while and quite possibly not much more than that and certainly no permanent damage as a result.“ Contrary to the loudly expressed view of so many politicians, this specialist of 25 years‘ experience told us that when heroin is properly used by doctors, it is „a very safe drug“.

Until the American prohibitionists closed him down in the 20s, Dr Willis Butler ran a famous clinic in Shreveport, Louisiana, for old soldiers and others who had become addicted to morphine after operations. Among his patients, he included four doctors, two church ministers, two retired judges, an attorney, an architect, a newspaper editor, a musician from the symphony orchestra, a printer, two glass blowers and the mother of the commissioner of police. None of them showed any ill effect from the years which they spent on Dr Butler’s morphine. None of them died as a result of his prescriptions. And, as Dr Butler later recalled: „I never found one we could give an overdose to, even if we had wanted to. I saw one man take 12 grains intravenously at one time. He stood up and said: ‚There, that’s just fine,‘ and went on about his business.“

Heroin can be highly addictive – which is a very good reason not to start taking it. In extreme doses, it can kill. But the truth which has been trampled under the cavalry of the drug warriors is that, properly prescribed, pure heroin is a benign drug. The late Professor Norman Zinberg, who for years led the study of drug addiction at Harvard Medical School, saw the lies beneath the rhetoric: „To buttress our current programme, official agencies, led originally by the old Federal Bureau of Narcotics, have constructed myth after myth. When pushers in schoolyards, ‚drug progression‘, drugs turning brains to jelly, and other tales of horror are not supported by facts, they postulate and publicise others: ‚drugs affect chromosomes‘; ‚drugs are a contagious disease‘. Officials go on manufacturing myths such as the chromosome scare long after they are disproved on the self-righteous assumption that if they have scared one kid off using drugs, it was worth the lie.“

Take away the lies and the real danger becomes clear – not the drugs, but the black market which has been created directly by the policy of prohibition. If ever there is a war crimes trial to punish the generals who have gloried in this slaughter of the innocent, the culprits should be made to carve out in stone: „There is no drug known to man which becomes safer when its production and distribution are handed over to criminals.“

Heroin, so benign in the hands of doctors, becomes highly dangerous when it is cut by black-market dealers – with paracetamol, drain cleaner, sand, sugar, starch, powdered milk, talcum powder, coffee, brick dust, cement dust, gravy powder, face powder or curry powder. None of these adulterants was ever intended to be injected into human veins. Some of them, such as drain cleaner, are simply toxic and poison their users. Others – sand or brick dust – are carried into tiny capillaries and digital blood vessels where they form clots, cutting off the supply of blood to fingers or toes. Very rapidly, venous gangrene sets in, the tissue starts to die, the fingers or toes go black and then have only one destiny: amputation. Needless suffering – inflicted not by heroin, but by its black-market adulterants.

Street buyers cannot afford to waste any heroin – and for that reason, they start to inject it, because smoking or snorting it is inefficient. The Oxford Handbook of Clinical Medicine records that a large proportion of the illness experienced by black-market heroin addicts is caused by wound infection, septicaemia, and infective endocarditis, all due to unhygienic injection technique. Street users invariably suffer abscesses, some of them of quite terrifying size, from injecting with infected needles or drugs. Those who inject repeatedly into the same veins or arteries will suffer aneurisms – the walls of the artery will weaken and bulge; sometimes they will start to leak blood under the skin; sometimes, these weakened arteries will become infected by a dirty needle and rupture the skin, leaving the user to bleed to death.

In the mid 90s, the World Health Organisation estimated that 40% of recent Aids cases internationally had been caused by drug users sharing injecting equipment. The British record on Aids is better because in the late 80s the government quietly broke with its prohibition philosophy and started to provide clean needles. Nevertheless, by June last year, 1,000 black-market drug users in this country had died of Aids which was believed to have been contracted from dirty needles. More needless misery and death.

Far worse, however, is the spread of hepatitis C, which can kill by causing cirrhosis and sometimes cancer in the liver. The official estimate is that 300,000 people in this country are now infected. Dr Tom Waller, who chairs Action on Hepatitis C, says the truth is likely to be much worse. And almost all of these victims are black-market drug users who contracted the disease by sharing dirty injecting equipment. Dr Waller says there is now a „major epidemic“, threatening the lives of „a great many people“. Needlessly.

Street buyers buy blind and so they will overdose accidentally: they have no way of telling how much heroin there is in their deal. Dr Russell Newcombe, senior lecturer in addiction studies at John Moores University in Liverpool, has found the purity of street heroin varying from 20% to 90%. „Users can accidentally take three or four times as much as they are planning to,“ he says. It is peculiarly ironic that governments set out to protect their people from a drug which they claim is dangerous by denying them any of the safeguards and information which they insist must apply to the consumption of drugs which they know to be harmless. (Compare, for example, the mandatory information on the side of a bottle of vitamin C tablets with the information available to a black-market heroin user.)

Street buyers often run short of supplies – and so they mix their drug with anything else they can get their hands on, particularly alcohol. Heroin may be benign, but if you mix it with a bottle of vodka or a handful of sedatives, your breathing is likely to become extremely depressed. Or it may just stop. In any event, whether it is poisonous adulterants or injected infection; whether it is death by accidental overdose or death by polydrug use: it is the black market which lies at the root of the danger. The healthiest route, of course, is not to take the drug at all: but for those who are addicted, prohibition inflicts danger and death. Needlessly. Water would become dangerous if it were banned and handed over to a criminal black market.

The same logic applies to drugs which, unlike heroin, are inherently harmful – such as alcohol, which is implicated in organic damage (liver) and social problems (violence, dangerous driving). American bootleggers brewed their moonshine with adulterants such as methylated spirits, which can cause blindness. (Hence the proliferation of blind blues singers.) And there are documented cases of drinkers during prohibition injecting alcohol, with all of the attendant dangers. (It is instructive to look back on the prohibitionists‘ efforts to justify their war against alcohol with hugely inflated statements of its danger. In his book on the history of drugs, Emperors of Dreams, Mike Jay records the claims that alcohol was an „environmental poison“ which generated cretinism and several otherwise unrecognised syndromes including „blastophoric degeneration“ and „alcoholic diathesis“.)

The risks of consuming LSD and ecstasy are increased enormously by their illegal and unsupervised manufacture. Nobody knows what they are swallowing. Yet, when a Brighton company developed a test to check the purity of ecstasy, the government’s drugs adviser, Keith Hellawell (whose contract has just been suspended), condemned it and warned that the company risked prosecution. It is the same with black-market amphetamines: speed alone may not kill, but speed with a blindfold is highly likely to finish you off.

In the same way, the classic signs of social exclusion among addicts are the product not of their drug but of the illegality of the drug. If addicts fail to work, it is not because heroin has made them work-shy, but because they spend every waking minute of the day hustling. If addicts break the law, it is not because the drug has corrupted their morality, but because they are forced to steal to pay black-market prices. If addicts are thin, it is not because the drug has stripped away their flesh, but because they spend every last cent on their habit and have nothing left for food. Over and over again, it is the black market, which has been created by the politicians, which does the damage.

Keith Hellawell, the man to whom the government turned for advice on drugs, appeared to know none of this. When we interviewed him for a television programme, he insisted that heroin itself was dangerous and then repeatedly dodged requests to come up with any evidence at all to justify his claim. Subsequently, when we offered his department as much time as it would like to find any evidence, it failed to come up with anything at all and passed the question to the Department of Health, which also failed. It is fair to conclude that the government’s former drugs adviser did not know the first thing about heroin.

The confusion between the effect of the drug and the effect of the black market is exacerbated not only because of government policy but also because government statistics completely ignore this distinction, with the result that teams of researchers study drug policy, use compromised statistics and simply recycle the confusion, thus providing politicians with yet more false fuel for their fire. Home Office figures on drug deaths, for example, are hopelessly compromised. Eighteen months ago, the Department of Health, which might have been expected to know better, produced new guidelines for doctors dealing with drug users and recorded the following: „Generally there is a greater prevalence of certain illnesses among the drug misusing population, including viral hepatitis, bacterial endocarditis, HIV, tuberculosis, septicaemia, pneumonia, deep vein thrombosis, pulmonary emboli, abscesses and dental disease.“ All of it true of the black market. None of it true of the drug. No attempt to make the distinction.

The black market damages not only drug users but the whole community. Britain looks back at the American prohibition of alcohol in the 20s and shudders at the stupidity of a policy which generated such a catastrophic crimewave. Yet in this country, now, the prohibition of drugs has generated a crime boom of staggering proportions. Research suggests that in England and Wales, a hard core of black-market users is responsible for some £1.5bn worth of burglary, theft and shoplifting each year – they are stealing £3.5m worth of property a day. As a single example, Brighton police told us they estimate that 75% of their property crime is committed by black-market drug users trying to fund their habit. And yet governments refuse to be tough on the cause of this crime: their own prohibition policy.

The global version of this damage was put succinctly by Senator Gomez Hurtado, former Colombian ambassador to France and a high court judge, who told a 1993 conference: „Forget about drug deaths and acquisitive crime, about addiction and Aids. All this pales into insignificance before the prospect facing the liberal societies of the west, like a rabbit in the headlights of an oncoming car. The income of the drug barons is an annual $500,000m, greater than the American defence budget. With this financial muscle they can suborn all the institutions of the state and, if the state resists, with this fortune they can purchase the firepower to outgun it. We are threatened with a return to the dark ages of rule by the gang. If the west relishes the yoke of the tyrant and the bully, current drug policies promote that end.“

Having attacked and maimed and killed the very people they claimed to be protecting; having inflicted a crime wave on the same communities which they said they were defending; having run up a bill which now costs us some £1.7bn a year in this country alone: this war’s generals might yet have some claim to respect if they were able to show that they had succeeded in their original objective of stopping or, at least, of cutting the supply of prohibited drugs. They cannot.

In December 1999, the chief constable of Cleveland police, Barry Shaw, produced a progress report on the 1971 Misuse of Drugs Act, which marked the final arrival of US drugs prohibition in this country: „There is overwhelming evidence to show that the prohibition-based policy in this country since 1971 has not been effective in controlling the availability or use of proscribed drugs. If there is indeed a war against drugs, it is not being won … Illegal drugs are freely available, their price is dropping and their use is growing. It seems fair to say that violation of the law is endemic, and the problem seems to be getting worse despite our best efforts.“

Mr Shaw was able to point to a cascade of evidence to support his view: between 1987 and 1997, there had been a tenfold increase in the seizure of illicit drugs, and yet the supply on the streets was so strong that the price of these drugs had kept dropping; in 1970, only 15% of people had used an illegal drug, but by 1995, 45% had; in 1970, 9,000 people were convicted of a drugs offence but in 1995 94,000 were. The Home Office responded to the chief constable’s report with complete silence: they refused even to acknowledge receiving it. Internal reports from the American Drugs Enforcement Agency confirm the chief constable’s conclusion. (They say Britain now produces so much cannabis that we actually export it to Holland.)

Prohibition has not merely failed to cut the supply of illicit drugs: it has actively spread drug use. The easiest way for new users to fund their habit is to sell drugs and consume the profit; so they go out and find new users to sell to; so it is that when one child in the classroom starts using, others soon join in; one user in the street and neighbours soon follow. Black-market drug use spreads geometrically. The Health Education Authority in 1995 found that 70% of people aged between 11 and 35 had been offered drugs at some time. Pushers push. When Britain began to impose prohibition of heroin, in 1968, there were fewer then 500 heroin addicts in Britain – a few jazz musicians, some poets, some Soho Chinese. Now, the Home Office says there may be as many as 500,000. This is pyramid selling at its most brilliantly effective.

In private, the Home Office’s best defence is that it is so short of reliable intelligence on drugs that nobody can finally prove that the war is lost: we simply don’t know how much heroin or cocaine is imported, or how many people are using it.

Keith Hellawell argued that the 30 years since the Misuse of Drugs Act do not really count, because, until he took over, British governments did not have a real strategy. He told us he was supporting new international tactics (which he could not divulge) and was now seeing figures (which he could not give us) to suggest finally they were going to succeed. This recalls earlier declarations that „We have turned the corner on drug addiction“ (President Nixon, 1973), or „Heroin availability continues to shrink“ (DEA, 1978). In the meantime, world heroin production has tripled in the past decade, cocaine production has doubled and, in the foreign secretary’s Blackburn constituency, police say drug use in the Asian community has soared by 300% in four years.

But the underlying point is even more worrying: once you understand that the real danger comes from the black market and not from the drug, you can see that even if, with some magic formula, the generals started to cut the supply of these drugs, the result would be disastrous. The price of heroin, for example, would start to rise and, since there is no evidence at all that heroin addicts cut their consumption to fit their wallets, they would have to commit more crime to fund their habits. And if the dealers also responded like good entrepreneurs, they would try to keep their prices down by adding even more pollutants to the heroin, thus increasing the health risks to users.

This government has not begun to consider legalisation. No matter the truth about the danger and the death, no matter the truth about the cause of crime, the position is, as Jack Straw put it to the 1997 Labour conference: „We will not decriminalise, legalise or legitimise the use of drugs.“ Why? The obvious answer was offered to us by Paul Flynn, Labour backbencher and staunch opponent of prohibition: „It is being fuelled by politicians who are vote gluttons, who believe that there is popularity and votes to be gained by appearing to be tough on drugs.“

While Keith Hellawell and other prohibitionists are embarrassed by their screaming lack of success, those who want to legalise can point to clear evidence that providing a clean supply of drugs will help with the physical and mental health of users, will cut crime in the community and drain the life out of the black market.

The Swiss, for example, in 1997 reported on a three-year experiment in which they had prescribed heroin to 1,146 addicts in 18 locations. They found: „Individual health and social circumstances improved drastically … The improvements in physical health which occurred during treatment with heroin proved to be stable over the course of one and a half years and in some cases continued to increase (in physical terms, this relates especially to general and nutritional status and injection- related skin diseases) … In the psychiatric area, depressive states in particular continued to regress, as well as anxiety states and delusional disorders … The mortality of untreated patients is markedly higher.“ They also reported dramatic improvements in the social stability of the addicts, including a steep fall in crime.

There are equally impressive results from similar projects in Holland and Luxembourg and Naples and, also, in Britain. In Liverpool, during the early 1990s, Dr John Marks used a special Home Office licence to prescribe heroin to addicts. Police reported a 96% reduction in acquisitive crime among a group of addict patients. Deaths from locally acquired HIV infection and drug-related overdoses fell to zero. But, under intense pressure from the government, the project was closed down. In its 10 years‘ work, not one of its patients had died. In the first two years after it was closed, 41 died.

There is room for debate about detail. Should we supply legalised drugs through GPs or specialist clinics or pharmacists? Should we continue to supply opiate substitutes, such as methadone, as well as heroin? Should the supply be entirely free of charge to guarantee the extinction of the black market? How would we use the hundreds of millions of pounds which would be released by the „peace dividend“? But, if we have any compassion for our drug users, if we have any intention of tackling the causes of crime, if we have any honesty left in our body politic, there is no longer any room for debate about the principle. Continue the war against drugs? Just say no.

 

source: http://www.guardian.co.uk/politics/2001/jun/14/drugsandalcohol.socialsciences



Prescribing heroin to heroin addicts is a strategy beloved by top police officers1 and successive home secretaries.2 It is a strategy, though, borne of utter frustration at our seeming inability to tackle an escalating drug problem. If you cannot stop addicts committing crimes to fund their drug habit then, so the argument goes, the next best thing is to provide them with the drugs that are the reason they are committing the crimes in the first place. The logic may seem faultless, but at the back of your mind is the nagging question, “Is it treatment or is it social problem prescribing?”

The evidence in relation to heroin prescribing is far from conclusive. On the positive side Nordt and Stohler have suggested that heroin prescribing led to a large reduction in incidence of heroin addiction in Switzerland, although the authors also point out that such prescribing may have reduced individual’s inclinations to cease their heroin use.3 A London study found no health benefits associated with heroin prescribing,4 whereas various Dutch and Swiss heroin trials have identified a range of benefits including improved social functioning and psychological and physical health.5 6 What is often quite difficult to identify from these studies is the degree to which the improved outcomes are the result of the heroin prescribed or other elements of the therapeutic programme provided. The cost of treating an addict with heroin is estimated to be three to four times that of treating an addict with methadone.7

Risks of prescribing

In the face of the additional costs and inconclusive evidence, many clinicians are wary of prescribing heroin. Their anxieties are understandable, given the high profile cases of doctors who have prescribed heroin to addicts and then subsequently found themselves facing a General Medical Council inquiry into their prescribing practices.8

At a clinical level prescribing heroin to heroin addicts is a risky strategy. Once you start, it is difficult not to feel that you have ceded authority for your prescribing to your patient. What, for example, do you say to patients who threaten to resume their previous life of crime if you reduce their heroin prescription? What do you say to the cocaine addict who asks why he cannot have cocaine provided in the same way as the heroin addict? Opening up heroin prescribing to addicts could lead to massive pressure on doctors to prescribe increasing amounts of the drug.

It was in part as a result of that pressure that the Interdepartmental Committee on Drug Addiction advised the UK government in 1965 that only appropriately certified doctors should prescribe heroin to addicts. The committee’s decision was influenced by the case of Lady Frankau, a noted London psychiatrist who in 1962 prescribed more than 600 000 heroin tablets to her addict patients.9

What are we treating?

Prescribing heroin to heroin addicts, however, makes sense only if your primary concern is to treat not their drug dependency but the consequences of their drug use. You may want to reduce their use of street drugs, the risks to health from HIV or hepatitis C virus, the risks of overdose, or their criminality. With all of these aims in mind you may conclude that it makes sense to provide addicts with a prescription for the drug that they have become dependent on. And yet the reason they are committing those crimes, and taking such enormous and persistent risks with their health, is because the drugs have become more important than life itself—that is the nature of drug addiction. And that is the problem that drug treatment services need to tackle.

Research has shown that with the right services in place it is possible to do more than simply stabilise addicts’ continued drug use through the prescribing route. For example, the Australian treatment outcome study, which followed up 429 heroin users recruited from a random sample of drug treatment agencies 36 months after starting treatment, found that 40% of drug users had been abstinent for the preceding 12 months and 25% had been abstinent for the preceding 24 months.10 In a similar Scottish study of 695 addicts, re-interviewed 33 months after they had started treatment for drug misuse, 29.4% of those who had been provided with residential rehabilitation had been abstinent for at least 90 days before being interviewed compared with only 3.4% of those receiving methadone maintenance.11 All of the residential rehabilitation services included in this study followed an abstinence based programme.

But do addicts coming forward for treatment actually want heroin to be prescribed to them? A study of over 1033 drug users starting treatment in 2001 asked participants what they wanted to get from the drug treatment services they were contacting.12 Most of those questioned said that they wanted the services to help them become drug free. Health services need to ensure that they are supporting addicts’ attempts to become drug free, and they need to be extremely cautious about any extension of a policy that could be seen as a route to maintaining rather than reducing an individual’s drug dependency.

Footnotes

References

  1. Bright M. Police urge major rethink on heroin. Observer2001 Dec 9.
  2. Blunkett D. David Blunkett’s speech on cannabis. Guardian2002 Jul 10.
  3. Nordt C, Stohler R. Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis. Lancet2006;367:1930-4.
  4. Hartnoll R, Mitcheson MC, Battersby A, Brown G, Ellis M, Flemming P, et al. Evaluation of heroin maintenance in controlled trial. Arch Gen Psychiatry1980;37:877-84.
  5. Van den Brink W, Hendricks V, Blanken P, Koeter M, van Zweiten B, van Ree J. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ2003;327:310.
  6. Uchtenhagen A, Dobler-Mikola A, Steffen T, Gutzwiller F, Blatter R, Pfeifer S. Prescription of narcotics for heroin addicts: main results of Swiss national cohort study. Basel: Karger, 1999.
  7. Stimson G, Metrebian N. Prescribing heroin what is the evidence?. York: Joseph Rowntree Foundation, 2003.
  8. Dyer O. Seven doctors accused of over-prescribing heroin. BMJ2007;328:483.
  9. Interdepartmental Committee on Drug Addiction. Drug addiction in the United Kingdom; the second report of the interdepartmental committee on drug addiction. London: HMSO, 1965.
  10. Darke S, Ross J, Mills K, Williamson A, Harvard A, Teesson M. Patterns of sustained heroin abstinence among long term dependent heroin users: 36 months findings from the Australian treatment outcome study. Addict Behav2007;32:1897-1906.
  11. McKeganey N, Bloor M, Robertson M, Neale J, MacDougal J. Abstinence and drug abuse treatment: results for the drug outcome research in Scotland study. Drug Educ Prev Policy2006;13:537-50.
  12. McKeganey N, Morris Z, Neale J, Robertson M. What are drug users looking for when they contact drug services: abstinence or harm reduction? Drugs Educ Prev Policy2004;11:423-35.

Some heroin addicts are very difficult to treat. Jürgen Rehm and Benedikt Fischer believe that maintenance with heroin is the way forward for this group, but Neil McKeganey argues that it is treating the effects of misuse not the addiction

Recently, a public hearing of a Danish parliament subcommittee discussed whether heroin assisted maintenance treatment should be offered experimentally to reduce health and social harm related to use of heroin (www.tekno.dk/ordineret-heroin). This is just one in a series of similar—existing or proposed—programmes in Europe, North America, and Australia.1 We believe that such treatment is appropriate for heroin misusers under certain circumstances.

Supporting evidence

Increasing heroin misuse in the United States in the early 1970s led to a public debate about prescribing heroin as a last resort form of opioid maintenance therapy for people with chronic heroin dependence. In 1973 Lorrin Koran advocated in the New England Journal of Medicine that “carefully designed clinical research on the safety and efficacy of heroin maintenance should be undertaken, particularly with addicts not helped in current treatments.”2 Some 35 years later, three important research studies have been completed. In Switzerland, a small randomised trial3 and a study using natural cohort designs4 found heroin assisted maintenance treatment to be feasible and effective for a group of heroin misusers who were refractory to treatment, as characterised by long term heroin dependence; physical, psychological, or social deficits; and unsuccessful previous treatment.4 5 Effectiveness was observed in treatment retention; somatic health outcomes such as epileptic episodes, abscesses, or cachexia; mental health outcomes such as affective or anxiety disorders; heroin and cocaine misuse; and criminal outcomes such as property offences or drug trafficking (on the basis of self report and objective measures).5

Large randomised controlled clinical trials in the Netherlands and Germany, which compared different modes of heroin assisted maintenance treatment with methadone maintenance treatment, obtained positive results on similar outcomes.6 7 Moreover, heroin assisted maintenance treatment was found to be cost beneficial in Switzerland8 and cost effective in the Netherlands compared with methadone maintenance treatment.9 Since these results were obtained, this treatment option has been extended beyond the trial periods, and heroin has been approved by the regulatory bodies for treating opioid dependence. In all three countries, the intake of medical heroin is supervised and occurs a maximum of three times a day, and patients recover from acute intoxication before leaving the treatment clinic. Notably, heroin has been a treatment option for heroin misusers in the United Kingdom for several decades, albeit on a relatively small scale and under different conditions—with lower average dosing and less supervised intake.10

Use of maintenance

The above summary makes the recent use of heroin assisted maintenance treatment look like a straightforward scientific success story, and not like a topic for debate in the BMJ. However, since the original heroin assisted maintenance treatment programme was proposed in Switzerland in the early 1990s, there has been scientific, and perhaps more importantly, larger public debate on the ethics, safety, and clinical value of prescribing heroin, and to a lesser degree, on maintenance treatment in general. Overall, maintenance with buprenorphine and, to a larger degree, methadone is more successful than treatment focusing on abstinence or using placebos.11 Given the nature of opioid dependence as a chronic relapsing disease,12 these results are not surprising.

Opioid maintenance treatment generally seems to be well justified for treating this disease. And if maintenance is generally justifiable as a form of treatment, why should heroin not be used as one such pharmacological agent? One reason that has been cited is safety, both for the patient13 and for the general public (for example, through diversion or the risk of trivialising the dangers of heroin, leading to an increase in use). Results from the Swiss studies, however, show that mortality among patients in heroin assisted maintenance programmes is low, and lower than for patients in other maintenance programmes.14 In addition, the wider safety concerns could not be empirically confirmed in Switzerland or the Netherlands.15 Finally, the incidence of heroin dependence has decreased greatly in Switzerland since the start of the trials, and currently heroin has a more negative image than it did 15 years ago.16

Overall, we see no convincing reason why heroin assisted maintenance treatment should not be part of a comprehensive treatment system for opioid dependence. However, the development of an overall integrated treatment system is crucial. All studies to date have been conducted in samples of refractory addicts with severely compromised health and several previous failed attempts of methadone maintenance treatment. Our current knowledge about the effectiveness of heroin assisted maintenance treatment is restricted to these groups and to the context of countries where there is already an established and effective comprehensive system for treating opioid dependence. Although we currently do not have the necessary empirical evidence for establishing heroin assisted maintenance treatment in other circumstances, addition of heroin assisted maintenance treatment would be likely to improve the overall treatment system, especially with respect to so called treatment resistant and refractory opioid addicts.

Footnotes

References

  1. Fischer B, Oviedo-Joekes E, Blanken P, Haasen C, Rehm J, Schechter M, et al. Heroin-assisted treatment (HAT) a decade later: a brief update on science and politics. J Urban Health2007;84:552-62.
  2. Koran L. Heroin maintenance for heroin addicts: Issues and evidence. N Engl J Med1973;288:654-60.
  3. Perneger T, Giner F, del Rio M, Mino A. Randomized trial of heroin maintenance programme for addicts who fail in conventional drug treatments. BMJ1998;317:13-8.
  4. Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet2001;358:1417-20.
  5. Uchtenhagen A, Dobler-Mikola A, Steffen T, Gutzwiller F, Blattler R, Pfeifer S, eds. Prescription of narcotics for heroin addicts: main results of the Swiss national cohort study. Basel: Karger, 1999.
  6. Van den Brink W, Hendriks V, Blanken P, Koeter M, van Zwieten B, van Ree J. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ2003;327:310-5.
  7. Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D. Heroin assisted treatment for opioid dependence: a randomised, controlled trial. Br J Psychiatry2007;191:55-62.
  8. Frei A. Economic evaluation of the Swiss project on medically prescribed heroin substitution treatment. Psychiatrische Praxis2001;28:S41-4.
  9. Dijkgraaf M, van der Zanden B, de Borgie C, Blanken P, Van Ree J, Van den Brink W. Cost utility analysis of co-prescribed heroin compared with methadone maintenance treatment in heroin addicts in two randomised trials. BMJ2005;330:1297.
  10. Metrebian N, Carnwath Z, Mott J, Carnwath T, Stimson G, Sell L. Patients receiving a prescription for diamorphine (heroin) in the United Kingdom. Drug Alcohol Rev2006;25:115-21.
  11. Amato L, Davoli M, Perucci C, Ferri M, Faggiano F, Mattick R. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. J Subst Abuse Treat2005;28:321-9.
  12. Leshner A. Addiction is a brain disease, and it matters. Science1997;278:45-7.
  13. Stoermer R, Drewe J, Dursteler-Mac Farland K, Hock C, Mueller-Spahn F, Ladewig D, et al. Safety of injectable opioid maintenance treatment for heroin dependence. Biol Psychiatry2003;54:854-61.
  14. Rehm J, Frick U, Hartwig C, Gutzwiller F, Gschwend P, Uchtenhagen A. Mortality in heroin-assisted treatment in Switzerland 1994-2000. Drug Alcohol Depend2005;79:137-43.
  15. Bammer G, van den Brink W, Gschwend P, Hendriks V, Rehm J. What can the Swiss and Dutch trials tell us about the potential risks associated with heroin prescribing? Drug Alcohol Rev2003;22:363-71.
  16. Nordt C, Stohler R. Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis. Lancet2006;367:1830-4.

1.1. The provision of foil for the purposes of smoking controlled substances,
generally heroin and crack cocaine, is illegal under section 9A of the Misuse
of Drugs Act 1971. However, some drug services provide foil to heroin users
as a cited harm reduction measure. Evidence has been provided to the
ACMD that some drug intervention agencies supply specialist foil to drug
users to encourage smoking as a safer alternative to the practice of injecting.
The foil generally comes with a specified health warning1.

1.2. In most cases foil is provided in packs, in ready cut sheets. It is noted that,
for the user, kitchen foil is not discreet to carry and is often coated with
vegetable oil that is generally burned off before use.

1.3. The ACMD began its consideration of the issue of the use of foil as a harm
reduction measure in July 2008 after a growing body of evidence of its
potential benefits and also its distribution from drug services.

1.4. Evidence has been presented to the ACMD that the legislation (Section
9A of the Misuse of Drugs Act 1971) is broadly un-enforced; with respect to
drug services providing foil in apparent contravention of the Misuse of Drugs
Act 1971. The ACMD understands that there are various reasons for this: 1) it
is a low policing priority; rather than expend effort collecting evidence and
preparing a file for the Crown Prosecution Service (CPS) they would take a
crime prevention approach and inform those services that were providing foil
that they should stop; 2) it is reported that some forces are ‘supportive’ of the
provision of foil as a harm reduction initiative and have, upon request,
supplied ‘letters of comfort’ which clarifies that they will not produce a report
to the CPS for prosecution.

1.5. According to the Health Protection Agency (2009), there is some
uncertainty about the extent of injecting drug use in the United Kingdom. It
may be as high as 217,000 in England and Wales alone. What is certain is
that people who inject drugs are especially vulnerable to a wide range of
infections. These include viruses such as hepatitis C (HCV) and HIV and also
bacteria such as group A streptococci or Clostridium botulinum. High rates of
mortality and illness arise from these infections so public health and
protective behaviour interventions among injecting drug users (IDU) are
important.

1.6. In its 2009 report The primary prevention of hepatitis C among injecting
drug users, the ACMD estimated that:

1 Details can be found at:
http://www.exchangesupplies.org/needle_exchange_supplies/foil/foil_intro.html

“There are 120,000 to 300,000 (mid estimate 190,000) people that have
been infected with HCV in England and Wales, and about 50,000 in
Scotland. 85% became infected through injecting drug use.”

The report concluded that “Ultimately we need to stop injecting to reduce the
risk of HCV”.

2. Background to the evidence underpinning ACMD’s previous
considerations and recommendations regarding
paraphernalia [under section 9A of the Misuse of Drugs Act
1971]

2.1. The ACMD first considered sterile water for injecting (WFI) in 1991 and
other drug paraphernalia in 1995. The issue was raised again at an ACMD
meeting in November 1998. Concern had been expressed that drugs workers
were putting themselves at risk of prosecution when supplying paraphernalia
in breach of the law.

2.2. A number of reports and studies were discussed at the November 2000
ACMD Technical Committee meeting:

2.2.1. A report by the Royal Pharmaceutical Society of Great Britain
(RPSGB) had recommended that section 9A should be amended to
permit the supply of injecting paraphernalia by pharmacists to drug
misusers.

2.2.2. A report of the Police Foundation’s Inquiry into the Misuse of Drugs
Act 1971 (Police Foundation, 2000) had also recommended that
section 9A should be repealed.

2.2.3. A paper by Sheridan et al. (2000) examined the supply of syringes
and other injecting equipment by needle exchange schemes in
South-East England. The researchers collected data from
approximately 400 community pharmacists and needle exchanges;
the responses had indicated that 83% of needle exchanges supplied
swabs and 6% supplied filters.

2.2.4. Research by Crofts et al. (2000) found detectable levels of hepatitis
C virus on injecting equipment other than needles or syringes – which
suggested that infection could be transferred to syringes (and
individuals) through sharing paraphernalia. The virus had been
detected on 70% of syringes, 67% of swabs, 40% of filters, 25% of
spoons and 33% of water samples.

2.3. The ACMD considered a paper on the supply of drugs paraphernalia at its
meeting in November 2000. The ACMD considered drug paraphernalia and
WFI at its meeting in May 2001 and subsequently the use of filters in May
2003.

2.4. In May 2001, the ACMD made its recommendation to amend the misuse
of drugs legislation to permit the supply of swabs, bowls, spoons, stericups,
citric acid and WFI. In May 2003, the ACMD recommended the inclusion of
generic filters in the legislation. These recommendations were accepted by
government.

3. Current legal position and background

3.1. Section 9A(1) of the Misuse of Drugs Act 1971, below, makes it an offence
to supply any article used for administering a controlled drug unlawfully (i.e.
without a doctor’s prescription).

“A person who supplies or offers to supply any article which may be
used or adapted to be used (whether by itself or in combination with
another article or other articles) in the administration by any person
of a controlled drug to himself or another, believing that the article
(or the article as adapted) is to be so used in circumstances where
the administration is unlawful, is guilty of an offence.”

3.2. Section 9A was inserted in the 1971 Act by the Drug Trafficking Act 1986.
The purpose was to outlaw the supply of cocaine kits (razor blades, foil and
lemon juice) that were being marketed in the mid-1980s. An exception was
made for sterile syringes and needles to permit the supply of clean injecting
equipment to drug users because of their significant harm reducing benefits,
including reducing the spread of HIV, hepatitis B and hepatitis C and other
water and blood-borne diseases.

3.3. The ACMD was previously asked to consider whether the supply of
additional items of paraphernalia should be lawful. (It had become clear that
some pharmacists and drug workers in needle exchanges were supplying
such other items contrary to Section 9A in the belief that they were effective in
reducing the harms associated with injecting drug use). In May 2001, the
ACMD concluded that certain items had significant harm reducing benefits
and recommended that the supply of swabs, utensils for the preparation
(spoons, bowls, cups and dishes), citric acid and ampoules of water for
injection (when supplied in accordance with the Medicines Act 1968) should
be lawful, but only if medical practitioners, pharmacists and persons
employed in the lawful provision of drug treatment services supplied them
and, from 2005 onwards, a supplementary prescriber. Whilst rejecting them in
2001, the ACMD subsequently recommended that the supply of filters should
be lawful in similar circumstances. Cross Government agreement was sought
by the Home Office and changes were made by secondary legislation –
Regulation 6A of the 2001 Regulations – in August 2003. (The ACMD
rejected the inclusion of tourniquets, concluding that the risks outweighed the
benefits). Following evidence that users injecting crack or freebase cocaine
tend to use ascorbic rather than citric acid and following the ACMD’s
recommendation, the 2001 Regulations were further changed in 2005 to
incorporate ascorbic acid.

2 According to the findings of an online survey conducted by the National Needle Exchange
Forum (NNEF) between October and November 2008.

3.4. In accordance with section 9A, the supply of any other article is prohibited
where the supplier believes that it will be “used in circumstances where the
administration [of a controlled drug] is unlawful”, but not otherwise. It is a
matter for the police and the crown prosecution service respectively to assess
what policing priority should be given and whether prosecution is in the public
interest where a drugs worker supplies articles in contravention of section 9A.

3.5. Despite the current legislation 15%2 of UK services have for some time
contravened section 9A by providing foil. Yet there are no cases of a service
being charged with an offence (Pizzey and Hunt, 2008).

3.6. The ACMD considers that any advice provided to ministers regarding
changes in respect of the Misuse of Drugs Act 1971 would need to fulfil two
criteria:

. for there to be evidence that the intervention reduced drug related harm;
and,

. the intervention would not encourage use of illegal drugs, especially
heroin.

4. Evidence presented to ACMD regarding the use of foil as a
harm reduction intervention

4.1. Two key studies provided evidence of how the provision of foil might reduce
harm among injecting drug misusers in the UK. A published study (Pizzey and
Hunt, 2008), provided an evaluation of results from an intervention in South
West England using foil packs to promote a transition away from heroin
injecting to inhalation. The study analysed data from four needle and syringe
programmes (NSPs) and interviews with injecting drug users (IDUs) in one
NSP. A Turning Point report (Boid and Waldock, 2008) described a trial
scheme entailing the introduction of aluminium foil to Sydney Street needle
exchange and Sharp Action needle exchange in Sheffield.

4.2. The report by Pizzey and Hunt (2008) showed that foil packs were taken
when available (out of 320 attendees, 54% took the foil packs). Over the
period of the evaluation, NSP transactions increased by 32.5% from 1,672 to
2,216.

4.3. The findings from the Pizzey and Hunt (2008) study suggested that
distributing foil packs could be a useful means of engaging needle and
syringe programme (NSP) attendees in discussions about ways of reducing
injecting risks – thereby reducing harms to users and providing a mechanism
of engagement to reduce overall use. It could also reduce injecting in settings
where there was a pre-existing culture of heroin chasing.

4.4. The study called for further research, to evaluate whether the study findings
(Pizzey and Hunt, 2008) could be reproduced in other cultural contexts and
evaluate whether the observed behavioural changes were sustained and led
to reductions in harm including blood-borne infections and overdose.

4.5. The Turning Point report (Boid and Waldock, 2008) details a trial scheme,
with feedback, where foil was provided at both a site based needle exchange
(423 packs provided) and an action van (304 packs provided). Whilst the
feedback received was not analysed it was apparent, from self reported
results, that the provision of foil reduced injecting behaviour and promoted
less risky alternatives.

4.6. The National Needle Exchange Forum (NNEF) undertook an online
questionnaire between October and November 2008, the results of which
were analysed by Liverpool John Moores University. The questionnaire
produced 445 responses from across the UK, these included responses from
managers, commissioners, service users and workers. The results of the
NNEF questionnaire (Chandler et al., 2009) found that 15% of services
provided foil while 67% of services had no provision due to the current legal
status. 92% of respondents felt that foil would help reduce harms and 81%
felt that foil would encourage drug users not to inject. Overall the
questionnaire indicated that respondents were supportive of foil being
supplied through needle exchange programmes. The NNEF recommended
that Aluminium Foil should be added to the current list of exemptions in
Section 9A of the Misuse of Drugs Act. The NNEF further requested a more
detailed assessment and review of Section 9A.

4.7. In February 2009 the Association of Chief Police Officers (ACPO) Drugs
Committee wrote to the ACMD to highlight that ACPO Drugs Committee
members had been aware that, during the last few years, a number of local
service providers had taken part in harm reduction initiatives and had
supplied foil to intravenous drug users in order to encourage a change in their
consumption habits. The ACPO Drugs Committee cited a scheme operating
in Somerset Drug and Alcohol Action Team (DAAT) which had received
prominence following its evaluation in 2008.

4.8. The ACPO Drugs Committee requested clarification of the legislative
framework provided to all parties involved in these schemes so that local
health professionals and police do not expose themselves to breaches of the
law. This is a difficult area since the ACMD is aware that on a local level
individual forces are providing ‘letters of comfort’, where requested, to needle
exchanges and services. These letters do not have any legal standing, but
are a statement that effectively turns a blind eye to the provision of foil by
services.

4.9. Release provided a submission to the ACMD in March 2009 that supported
an amendment to section 9A to include foil in the exempted paraphernalia list.
Release recommended that:

. There should be an immediate review of section 9A and how it
impacted on the development of harm reduction initiatives;

. Consideration to be given to a new system led by medical opinion
whereby those working in this area could dispense equipment if it
could be shown to have an effective impact in reducing harm and/or
acting as a tool for engagement.

4.10. A study by Exley (2008) tested the hypothesis that aluminium foil could be
a significant source of aluminium in users of heroin who were ‘chasing the
dragon’. These experiments used the same ‘batch’ of street heroin. While
there was evidence of an increase in bio-available aluminium from heroin
vaporised off aluminium foil this would not account for the elevated urinary
excretion of aluminium in heroin users. According to a case study aluminium
had been found as a contaminant of heroin; e.g. 42 – 2280 µg aluminium g-1
heroin (Bora et al., 2002). The study also measured the aluminium content of
‘street’ heroin and found; 48.0 . 19.6 µg aluminium g-1 heroin (n=9). In
comparison the aluminium content of tobacco has been found to be; 600-
3700 µg g-1 (Exley et al., 2006) the aluminium content of heroin is generally
too low to account for the high urinary excretion of aluminium from heroin
users.

4.11. A presentation on the Dutch experience (Kools, 2009) provided an
overview of the supply of foil in the Netherlands. The Dutch aim was to
promote a move away from drug administration by injecting towards less risky
methods, a practice known as ‘route transition’. It described autonomous
trends among opiate and stimulant users from injecting towards non-injecting
drug consumption in the early 1990s. This trend in the drug using community
was initially recorded in 1992 and became the basis for a range of health
interventions to promote a shift away from injecting.

4.12. In the Netherlands, the provision of a combination of a full range of health
interventions (Opiate Substitution Therapy – OST), NSPs, consumption
rooms, community outreach, peer support, social marketing etc.) led to
significant individual and public health benefits.

4.13. Currently within the Netherlands foil is available in all needle and

syringe exchange programmes (NSEP) and consumption rooms (CR). It was
highlighted that a success recorded from the intervention had been a
significant reduction of blood-borne viruses (BBVs) (Kools, 2009). In
Amsterdam during the last decade “HIV prevalence had fallen from 8.5 per
cent to virtually zero, and the number of fatal overdoses had also drastically
decreased” (Kools, 2010).

4.14. The ACMD heard that provision of aluminum foil within NSEPs and CR

had not encouraged new users to take up illicit drugs.

4.15. In Scotland, Glasgow Addiction Services have proposed a foil exchange

pilot scheme. This followed encouraging results from a recent service user
evaluation. In October 2009 an anonymous service user questionnaire was
developed and distributed to service users to evaluate the service and
establish their views on foil provision. The key findings regarding foil were that
83% of service users said they would like foil to be offered as part of the
service and 59% said the provision of foil would encourage them to consider
smoking rather than injecting.

5. Consideration of the evidence

5.1. In all studies the benefits ascribed to the use of foil and the aims of
providing the foil were multi faceted. They included:

. To reduce injecting related harms (blood borne viruses, infections, vein
collapse);

. To reduce the risks of overdose;

. To reduce injecting drug use;

. To engage users to discuss options with a view to reduce harms,
injecting and ultimately drug use;

. To reduce drug related litter; and,

. To reduce drug related crime.

5.2. However, from the present studies it is difficult to specifically quantify the
reduction in injecting related harms since studies are not constructed to
measure this. Most of the studies to date have been qualitative in nature and
have been self-reported.

5.3. In the ACMD’s report on the primary prevention of hepatitis C (ACMD,
2009) it was noted that there was only weak evidence for the effectiveness of
many interventions in reducing HCV among IDUs. The key finding was that
there is emerging epidemiological evidence (supported by preliminary studies
in the UK) that the combination of opiate substitution therapy (OST) and NSP
is the most effective way of reducing HCV (and HIV) incidence among active
IDUs (NSP or OST alone may not be sufficient to prevent HCV). Transposing
the findings of the ACMD report (2009) it is likely that the provision of foil
alone, unless a total substitute for injecting behaviour, would not make any
significant impact on the incidence of blood borne viral infections.
Nonetheless, foil provision may have an important role within a programme of
interventions (like other paraphernalia) if it can be used to enforce harm
reduction messages on the dangers of injection.

5.4. The National Institute for Health and Clinical Excellence (NICE) Public
Health Guidance 18 Needle and syringe programmes: providing people who
inject drugs with injecting equipment recognises the importance of NSPs in
providing a gateway for IDUs to commence OST as a mechanism for
reducing harm. In this report is was also noted that from fieldwork findings of
participants who worked at Needle and Syringe Programmes:

‘They were disappointed that the draft guidance did not address the need
to provide foils and crack pipes to help people who inject to stop.’

• Afghan poppy harvest blighted by fungus
• Dealers adulterating supply to maintain profits

Hospitals are treating a growing number of drug users who have overdosed on heroin mixed with other substances by dealers because of a huge shortage of the opiate across the UK.

One of the most severe heroin ‚droughts‘ for five years has been reported in areas across the UK, including, London, Lancashire, Surrey, and Stockton-on-Tees.

The shortage has been linked not to seizures of the drug by law enforcement agencies but to a fungus that has blighted this year’s poppy crop in Afghanistan, reducing it by half.

Users are overdosing on either adulterated heroin, or, in some cases, what has been found to be a combination of a powerful sedative, caffeine and paracetamol. Some have become unconscious very soon after injecting or smoking it, while others have reported vomiting, flu-like symptoms and amnesia, drug agencies say.

One of the most recent reports of overdoses and hospital admissions came last week from Hastings, where four users overdosed even though they had only taken a small amount of what they thought was heroin. Toxicologist Dr John Ramsey, head of the Tictac Communications drugs database at St George’s medical school, London, said he had had about 50 recent requests to analyse adulterated heroin.

While sedatives of the type turning up in recent batches used to be found only in the occasional sample of heroin, there appeared to be much more of it around now, he said.

Gary Sutton, head of drugs at the charity Release, said: „There is a very significant heroin shortage across the UK at the moment. It has been going on for some time now, but the last two months have seen stockpiles exhausted.“

He expressed concern that what was being sold as heroin at the moment appeared to be adulterated with a powerful sedative and mixed with a high percentage of bulking agents like talcum powder or paracetamol.

„If people use this intravenously, perhaps on top of alcohol and methadone [the prescribed substitute drug for heroin], it is extremely risky. We have had many reports of people overdosing. It’s really important that accident and emergency departments understand that they may not be dealing with a ’normal‘ heroin overdose when people are brought in,“ he said.

„When the drought ends, prices will rise. Heroin tolerance will be reduced, so the risk of fatal overdose will be much higher.“

Such is the alarm about the current situation that several drugs agencies committed to harm reduction held an urgent meeting last week to discuss setting up an online warning system about contaminated street drugs.

Neil Hunt, director of research at KCA, a nationwide community drug treatment service, said: „This ‚heroin drought‘ appears to be serious and geographically widespread. Street heroin is in a complete and utter muddle at the moment, and users are collapsing unexpectedly. We need to standardise information about what’s out there.“

Among heroin users commenting in online forums about the drought, one long-term user said: „I’ve never known anything like it in 30 years.“

 

source: http://www.guardian.co.uk/society/2010/nov/21/heroin-shortage-uk-overdose-users

Some pharmacists in Vancouver’s Downtown Eastside routinely pay cash to drug addicts for filling their prescriptions, a CBC hidden-camera investigation has found.

The practice was revealed after several doctors complained that pharmacies were giving $10 a week or more to clients for each prescription filled if the drugs were dispensed daily. The daily prescription entitles the pharmacist to a daily dispensing fee, rather than a single fee for a long-term prescription.

A CBC hidden camera captured this image of a pharmacist giving cash to a customer filing a prescription on Vancouver's Downtown Eastside.

A CBC hidden camera captured this image of a pharmacist giving cash to a customer filing a prescription on Vancouver’s Downtown Eastside. (CBC)In the drug-ravaged neighbourhood, $10 cash buys a „rock“ of crack cocaine.

„All of a sudden we had a lot more [illegal-drug] dealers hanging around our clinic,“ said Dr. Helen Weiss of the Vancouver Native Health Clinic (VNHC) on East Hastings Street. „The cash deal is available to everyone who goes to certain pharmacies.“

„Now you have patients being very demanding and trying to be very directive as to what they should get in terms of their prescriptions,“ said Dr. David Tu. „There is a lot of frustration amongst the doctors.“

The more prescriptions a pharmacy fills for customers covered by PharmaCare — the provincial agency that uses taxpayers‘ money to help eligible British Columbia residents cover the cost of eligible prescription drugs — the more money it can charge.

Most of the addicts in the Downtown Eastside are covered by the plan.

The province pays pharmacies $8.60 each time they dispense a drug, even if it’s just a single pill handed out daily. On top of that, the pharmacies get an additional $7.70 per daily dose for dispensing methadone and supervising the patient as they drink it.

The doctors at VNHC believe that if the daily dispensing were eliminated, pharmacists would have no incentive to encourage daily prescriptions or pay kickbacks.

„It’s a waste of money, certainly — in the area of hundreds of thousands of dollars that could be so much better spent,“ Tu said.

‚All of a sudden we had a lot more [illegal-drug] dealers hanging around our clinic.‘— Dr. Helen Weiss

Recently, CBC placed a hidden camera on an addict who needed a prescription filled for Tylenol 3. He went into AYC Pharmacy, a few doors down from the VNHC, and asked the manager, Manji Farbeh, for a $10 payback.

„For this we don’t give you $10 — $5, just $5,“ Farbeh replied.

She explained she wouldn’t pay $10 because the addict’s prescription was only good for a week.

The addict, whom CBC News has agreed not to name, replied: „Five? Come on. How am I supposed to get a [cocaine] rock for five bucks?“

Farbeh laughed, then a pharmacist handed the addict a $5 bill. Outside the pharmacy, other customers told the addict they have been paid more.

„There was one time when I got my methadone they gave $30,“ said one female customer who was recorded by the hidden camera. A male customer added: „Ten bucks a week. That and 20 bucks every two weeks for my methadone.“

Bernadette Murphy, spokeswoman for B.C.’s Ministry of Health, said it is a violation of the pharmacist’s contract with government to pay customers for prescriptions.

„There are rules set out in the British Columbia PharmaCare Pharmacy Participation Agreement which basically says that no incentives shall be offered as an inducement to secure prescription orders,“ Murphy wrote in an e-mail.

Interview requested

CBC News requested an interview with the owner of AYC Pharmacy, where the addict with the hidden camera was given a cash incentive.

Nikhil Buhecha’s lawyer responded by letter, indicating he was willing to participate under certain conditions. Buhecha did not respond to subsequent phone calls. Buhecha also owns Abbott Renuka Pharmacy, which is also in Vancouver’s Downtown Eastside.

CBC News obtained prescription records for a patient who gets nine different pills dispensed daily at Buhecha’s pharmacies. From his business alone, the records show, the pharmacy could charge the province almost $2,400 a month in dispensing fees. At the $10-a-week cash rate per prescription, the cash payback to the customer could reach $400 a month.

Dr. Helen Weiss, left, and Dr. David Tu of the Vancouver Native Health Clinic say there is a lot of frustration among  doctors over the kickbacks for prescriptions.

Dr. Helen Weiss, left, and Dr. David Tu of the Vancouver Native Health Clinic say there is a lot of frustration among doctors over the kickbacks for prescriptions. (CBC)The doctors at VNHC said they’ve seen a sharp increase in patients asking for unnecessary and perhaps dangerous drugs.

„People come in and they are on multiple prescriptions,“ Weiss said. „People are trying to get on methadone who actually are not narcotic addicts simply because they can get a small [cash] incentive and then perhaps sell it on the street.“

Weiss said she watched as one of her patients was screamed at by her boyfriend because she didn’t get a prescription he could cash in.

Tu said a patient of his was given a dangerously high amount of methadone after she switched to a cash-paying pharmacy.

„They double-dosed her,“ Tu said. „She could have died, and we had to watch her for 24 hours.“

CBC News watched outside AYC Pharmacy early one morning as dozens of patients lined up to get their methadone. Several walked out with a Styrofoam cup full of liquid before drinking from it. Very few of them drank from their cups in front of the pharmacist.

Apparent rule violation

That is also an apparent violation of rules governing pharmacists, which state they are supposed to make sure patients drink all their methadone before leaving the premises.

Guidelines posted at the College of Pharmacists of B.C. website read: „After the patient drinks the methadone, a short conversation is required to ensure that the methadone has been swallowed. Confirmation … is necessary as some patients may try to keep the methadone in their mouth until they can spit it into a container.“

Doreen Littlejohn, a nurse with the nearby Native Health Society, confirmed that 10 patients surveyed recently said they often leave AYC with a full Styrofoam cup of methadone in hand.

„I asked everyone who came in that day if they are able to take their methadone with them, and they all said yes,“ Littlejohn said.

„There is a lot of methadone for sale on the street,“ Weiss said, „and it’s because people manage to walk out with it. That methadone has high street value and you sell it to someone — a very powerful narcotic — and they don’t know what they are doing and there can be overdoses.“

The doctors at VNHC wrote letters of complaint to the Ministry of Health and the B.C. College of Pharmacists. Weiss said PharmaCare’s director of pharmaceutical services, Bill Mercer, assured her in January of 2008 that tough action would be taken and asked her not to go to the media with her concerns.

„The people I spoke with genuinely seem concerned but I think they are very limited in what they can do,“ Weiss said, „partly because our patients have no credibility.“

7 months of silence

The VNHC doctors said they have heard nothing from the authorities in the seven months since they lodged their complaints.

„They need to investigate,“ Tu said. „They need to take these allegations seriously because the system is going to crumble if they don’t.“

Tu is especially worried the competitive pressure from pharmacies that pay kickbacks will drive those that don’t out of business.

B.C. Health Minister George Abbott said he is concerned about cash payments made for prescriptions on Vancouver's Downtown Eastside.

B.C. Health Minister George Abbott said he is concerned about cash payments made for prescriptions on Vancouver’s Downtown Eastside. (CBC)„Pharmacists are our partners,“ he said. „They are an essential part of the health-care system. We rely on them so heavily and then to have them be people that are behaving unethically according to their own pharmacy code, and in such ways that I feel that I can’t trust them — that’s what hurts. That’s what this is about, I think.“

„We are very concerned about this,“ B.C. Minister of Health George Abbott said. „If the practices as alleged are occurring as alleged then obviously there’s a range of remedies that we can employ, and that range of remedies would certainly include an end or termination of opportunity for the pharmacy in question to distribute methadone.“

Tu and Weiss believe the solution is simple: The province should pay pharmacists only one dispensing fee per prescription, not every time they dispense a single pill.

„If people weren’t making money out of these daily dispense meds, there wouldn’t be the need to be behaving this way,“ Weiss said. „If there was only a weekly dispensing fee at max, this wouldn’t happen.“

Read more: http://www.cbc.ca/canada/british-columbia/story/2008/09/07/bc-prescription-for-profit.html#ixzz160AC5OM0

Leistungen, die nicht den vertragsärztlichen Vorschriften entsprechen, dürfen von Vertragsärzten nicht erbracht und von Kassenärztlichen Vereinigungen nicht honoriert werden. Dies hat das Bundessozialgericht (BSG) entschieden. Streitig war die Vergütung für eine Substitutionsbehandlung, die im Widerspruch zur Richtlinie des Gemeinsamen Bundesausschusses (G-BA) zur Bewertung medizinischer Untersuchungs- und Behandlungsmethoden gemäß § 135 Absatz 1 SGB V stand.

Der Kläger, der als Arzt ohne Gebietszeichnung über eine Berechtigung zur Durchführung und Abrechnung von Methadon-Substitutionsbehandlungen bei manifest Opiatabhängigen verfügt, behandelte einen Versicherten von 1995 bis zu Beginn des Jahres 2005. Nachdem der Versicherte zwischendurch bei einem anderen Arzt in Behandlung gewesen war, meldete ihn der klagende Arzt im Juli 2005 erneut zur Substitutionsbehandlung an. Die Kassenärztliche Vereinigung (KV) ließ eine Evaluierung des Behandlungsfalls durch ihre Qualitätskommission durchführen, die zu der Auffassung gelangte, dass die Substitutionsbehandlung wegen des hohen Benzodiazepin-Konsums des Versicherten nicht mehr weitergeführt werden könnte. Die KV gab dem Kläger mit Bescheid auf, die Substitutionsbehandlung des Versicherten durch Ausschleichen spätestens zum 13. Februar 2006 zu beenden. Widerspruch und Klagen blieben ohne Erfolg.

Auch das BSG kommt zu der Auffassung, dass die Substitutionsleistungen des Arztes nicht mehr zu vergüten sind. Nach der Richtlinie des G-BA ist die Substitution zu beenden, wenn der Gebrauch von Suchtstoffen neben der Substitution ausgeweitet oder verfestigt wird. Die KV ist nicht gehindert, durch Verwaltungsakte die Vergütungsfähigkeit von Substitutionsleistungen ab einem bestimmten Zeitpunkt in der Zukunft zu verneinen. In der Entscheidung der KV, derartige Leistungen nicht als vertragsärztliche Leistungen anzusehen und nicht zu vergüten, liegt auch keine berufswidrige Weisung eines Nichtarztes. (Bundessozialgericht, Urteil vom 23. Juni 2010, Az.: B 6 KA 12/09 R) RAin Barbara Berner

dpa

London – Die Substitution von Drogen­abhängigen mit Methadon oder Buprenorphin ist nicht ohne Risiken. Vor allem in der ersten Woche und nach dem Abbruch der Therapie kommt es häufiger zu Todesfällen durch Überdosierungen.

Dennoch bessert die Substitutionsbehandlung die Überlebenschancen der Abhängigen, wie die Erfahrungen des britischen Substitutions­programms im britischen Ärzteblatt (BMJ 2010; 341: c5475) zeigen.

Die General Practice Research Database (GPRD), die weltweit größte Sammlung elektronischer Krankenakten, erfasst mittlerweile 3,5 Millionen britische Hausarzt-Patienten oder 5,5 Prozent der britischen Bevölkerung. Darunter sind auch 5.577 Patienten, die seit 1990 an einer Opiat-Substitution teilnahmen.

Anfangs wurde hierzu Methadon eingesetzt, inzwischen bevorzugen viele Ärzte Buprenorphin. Eines der Ziele der Therapie, die Senkung der Drogentoten, wurde nicht erreicht, schreibt die Gruppe um Matthew Hickman von der Universität Bristol, die die GPRD-Daten ausgewertet hat und dabei auf eine Erklärung für viele Todesfälle stieß.

178 Patienten, das sind immerhin 3 Prozent der Substituierten starben entweder in den ersten zwei Wochen der Substitution oder aber nach dem Ende oder dem Abbruch der Therapie. In den ersten beiden Wochen war die Sterberate dreimal höher und nach dem Ende sogar acht- bis neunfach höher als zu anderen Zeiten der Therapie.

Dafür gibt es laut Hickman nur eine Erklärung: eine Opiatüberdosierung. Sie droht zu Beginn der Substitution, wenn die Ärzte die benötigte Dosis zu hoch einschätzen, was vor allem beim Methadon leicht möglich sei.

Oder aber die Abhängigen spritzen entgegen der Absprachen weiterhin Heroin oder andere Opiate. Im Verlauf einer erfolgreichen Substitution sinkt die Opiattoleranz: Abhängige, die nach dem Ende wieder rückfällig werden und dabei mit der früheren Dosis beginnen, laufen Gefahr sich einen „goldenen Schuss“ zu setzen.

Trotz dieser Risiken ist das Sterberisiko unter der Substitutionstherapie niedriger als bei nicht behandelten Patienten. Deren Sterberate ist nämlich zehnmal höher als beim Rest der Bevölkerung und Drogenabhängige, die die Substitution über 12 Monate oder länger durchhalten, haben laut den Berechnungen von Hickmann eine 85-prozentige Chance ihre Sterblichkeit zu senken. © rme/aerzteblatt.de

Ron Price needs his milkshake. It’s 10 o’clock on a Monday morning and the bald-headed, barrel-chested former bodybuilder is shuffling around the kitchen of a posh rehab clinic in Tijuana, wearing slippers and a blue Gold’s Gym T-shirt. Price had been employed as a stockbroker in New Mexico, until his training regimen left him with debilitating injuries that forced him to undergo 33 surgeries in less than a decade. His doctor prescribed Oxycontin, and Price quickly became dependent on the potent painkiller. More recently, he started snorting cocaine and chugging booze to numb the pain. Now, 53 years old and three weeks into rehab, all he wants is a milkshake and to crawl back into bed.

Clare Wilkins, the vivacious 40-year-old director of Pangea Biomedics, pops the lid of the blender to check the consistency of the concoction Price craves: peanut butter, soy milk, agave syrup, hemp protein powder, and a few scoops of chocolate-flavored Green SuperFood.

Oh, and a half-teaspoon of root bark from the tabernanthe iboga plant.

Taken in sufficient quantity, the substance triggers a psychedelic experience that users say is more intense than LSD or psilocybin mushrooms. Practitioners of the Bwiti religion in the West African nation of Gabon use iboga root bark as a sacrament to induce visions in tribal ceremonies, similar to the way natives of South and Central America use ayahuasca and peyote. Wilkins is one of a few dozen therapists worldwide who specialize in the use of iboga (more specifically, a potent extract called ibogaine) to treat drug addiction.

Now she pours the thick, chocolatey liquid into a mason jar but agrees to hand it over to Price only on the condition that he’ll stay awake and out of bed and interact with his fellow residents and the staff. Price grudgingly agrees and takes a seat at the dining-room table. Sunlight pours in through a sliding-glass door that opens to a terrace with a sweeping view of the Pacific Ocean and the San Diego skyline in the distance.

„Ron, I remember when you called me [three weeks ago], you were crying on the phone. You were so devastated, you couldn’t leave the house,“ Wilkins says gently. „When you use, you end up alone in a bathroom or something. You need a community. As weird and misfits as we are, we need this sense of community. You need to learn to deal with being in your body each day instead of relying on the fucking ibogaine.”

Ibogaine and iboga root bark are illegal in the United States but unregulated in many countries, including Canada and Mexico. Wilkins, though, is hardly alone in her belief that iboga-based substances can be used as a legitimate treatment for drug addiction. Researchers at respected institutions have conducted experiments and ended up with hard evidence that the compound works—as long as you don’t mind the mindfuck.

„All drugs have side effects, but ibogaine is unique for the severity of its side effects,“ says Dorit Ron, a neurology professor at the University of California–San Francisco. „I think ibogaine is a nasty drug. But if you can disassociate the side effects from the good effects, there is a mechanism of action in ibogaine that reduces relapse in humans.“

Now, using chemical variations, scientists have devised ways to make ibogaine non-hallucinogenic. The trouble, say Wilkins and others who have used ibogaine, is that the psychedelic journey carries the secret to the drug’s success.

It was Hunter S. Thompson who introduced ibogaine to a wide audience, in the pages of Rolling Stone. Thompson was covering the 1972 presidential election, reporting what would eventually become Fear and Loathing on the Campaign Trail ’72. When Democratic contender Edmund Muskie acted strangely during a campaign stop in Florida, Thompson suggested that the candidate was taking ibogaine, „an exotic brand of speed“ that „nobody in the press corps had ever heard of.“

„It is entirely conceivable—given the known effects of ibogaine—that Muskie’s brain was almost paralyzed by hallucinations,“ Thompson wrote. „He looked out at that crowd and saw gila monsters instead of people . . . his mind snapped completely when he felt something large and apparently vicious clawing at his legs.“

The notion of Ed Muskie on an ibogaine bender was absurd, and Thompson knew it. Most experienced users say the drug is extremely unpleasant when ingested in large doses, causing severe nausea, vertigo, sleeplessness, and visions that can be nightmarish. The effects last up to 36 hours, and the strain can be so great that some users are bedridden for days after.

„I only took one capsule of extract. It was very weak, but it was still strong enough to make me puke for six hours,“ says Dana Beal, a New York–based activist and longtime lobbyist for ibogaine legalization. „I had my head in a wastebasket or sink or toilet the entire time. It’s aversive. I can tell you from personal experience that I don’t ever want to take it again.“

While Hunter Thompson brought ibogaine into popular parlance, credit for discovering the drug’s medicinal potential is widely attributed to a man named Howard Lotsof. Ten years before the events that gave rise to Fear and Loathing, Lotsof was a junkie living in New York. Having bought some ibogaine for recreational use, Lotsof was astounded to find that when the hallucinogen wore off, he no longer craved heroin. Days passed, and he didn’t experience any of the excruciating symptoms associated with kicking a dope habit.

Lotsof, who died earlier this year of liver cancer at age 66, devoted his life to making ibogaine available as an addiction treatment. He experienced a significant setback in 1967, when the U.S. government banned the drug, along with several other psychedelics. In 1970 officials categorized ibogaine as a Schedule I substance—on par with heroin, marijuana, and other drugs that by definition have „a high potential for abuse“ and „no currently accepted medical use.“

Eventually, Lotsof shifted his focus and began using ibogaine to treat heroin addicts at a rehab clinic in the Netherlands. In 1985, he obtained a U.S. patent for the use of ibogaine to treat substance abuse.

Longtime Yippie activist Dana Beal was charged with money laundering after police caught him carrying $150,000 in cash. He says the money was going to finance a Mexican ibogaine clinic.
Tom Kingsley Brown, a researcher from the University of California–San Diego, is studying whether ibogaine works long-term to quell addiction.

By the late ’80s, doctors and scientists were confirming what Lotsof knew: Ibogaine blocks cravings and withdrawal symptoms for many types of drugs, and opiates in particular.

„Its effects are pretty dramatic,“ says Dr. Kenneth Alper, an associate professor of psychiatry at New York University who specializes in addiction research. „I’ve observed this firsthand, and it’s difficult to account for.“

Dr. Stanley Glick, a pharmacologist and neuroscientist at Albany Medical College, was among the first researchers to test ibogaine on rats. Glick hooked up the rodents to IVs in cages with levers that allowed them to inject themselves with morphine.

“If the rats do it, you can be pretty sure that humans will abuse it if given the opportunity,” Glick explains. “It’s really the time-tested model of any human behavior.”

Strung-out rats dosed with ibogaine stopped pressing the lever that gave them morphine. Glick and other researchers have subsequently replicated the morphine results with other addictive drugs, including alcohol, nicotine, cocaine, and methamphetamine.In the early 1990s, Lotsof teamed with Dr. Deborah Mash, a neurologist and pharmacologist at the University of Miami, to study the effect of ibogaine on people. Mash was granted FDA approval to administer ibogaine in 1993 and was able to test the drug on eight people before the experiment came to an abrupt halt.

„I was unable to get it funded,“ Mash says. „We had the rocket ship on the launch pad, with no fuel.“

A few months after the FDA gave Mash the green light, a committee of academics and pharmaceutical-industry professionals assembled by the National Institute on Drug Abuse (NIDA) concluded that the U.S. government should not fund ibogaine research. Earlier that year, a researcher from Johns Hopkins University had found that rats injected with massive doses of ibogaine suffered irreparable damage to the cerebellum, the part of the brain that controls balance and motor skills. According to Dr. Frank Vocci, former director of treatment research and development at NIDA, the fact that ibogaine increases the risk of seizures for people addicted to alcohol or benzodiazepines such as Valium raised eyebrows as well.

„The question that was posed to them was, ‚Do you think that this could be a project that could result in, essentially, a marketable product?‘ “ Vocci recalls. „There was concern about brain damage, seizures, and heart rate. But it wasn’t so much that the ultimate safety of the drug was being damned, it was just felt that there were an awful lot of warts on this thing.“

Mash and Lotsof soon parted ways, on unfriendly terms. Lotsof sued his former colleague and the University of Miami in federal court in 1996, claiming that her research had infringed on his patent. A judge eventually ruled in favor of Mash and her employer, absolving them of wrongdoing.

Lotsof went his own way, mentoring fellow former addicts who opened ibogaine rehab centers abroad. Mash opened a private clinic on the Caribbean island of St. Kitts and administered ibogaine to nearly 300 addicts. „It really works,“ Mash says now. „If it didn’t work, I would have told the world it doesn’t work. I would have debunked it, and I would have been the most outspoken leader of the pack. That’s my scientific and professional credibility on the line.“

Clare Wilkins is one of Howard Lotsof’s protégés. Born in South Africa and raised in Los Angeles, she got hooked on heroin at the age of 20 while majoring in Latin American studies and psychology at Cornell University. Drug use led to depression and she dropped out her senior year. She’d been trying to get clean using methadone for eight and a half years when her younger sister learned about ibogaine via the Internet. Wilkins, then 30 years old and employed as bookkeeper, read up on the subject, started saving up, and in 2005 shelled out $3,200 for a session at the Ibogaine Association, a clinic in Tijuana.

The trip—in both senses of the word—changed her life.

„I received a direct message that I was washed in love,“ Wilkins says of her first encounter with the hallucinogen. „That the universe in its entirety is full of love and that courses through us and was there for me. There was this soul body, this light body that had no beginning and no end. My fingers had no end, there were atoms coming in and going out.

„It got me off methadone completely,“ she says. „My sense of shame about my addiction was washed away without having to practice with a therapist and talk, talk, talk.“

The experience was so profound that she elected to stay on at the clinic as a volunteer. Confident and chatty, with long brown curls and a disarming smile, Wilkins feels she has a knack for guiding patients through their ibogaine-induced spiritual awakenings.

„On ibogaine, all your walls come down,“ she says. „You can’t lie. You get an opportunity to look at yourself honestly and see how you respond. My role is to be there as a comfort. People compliment me by saying, “You knew exactly when to hold my hand.‘ ”

Clare Wilkins is director of Pangea Biomedics, a rehab clinic in Tijuana's Playas neighborhood that administers ibogaine to drug addicts. 

Keegan Hamilton
Clare Wilkins is director of Pangea Biomedics, a rehab clinic in Tijuana’s Playas neighborhood that administers ibogaine to drug addict

Bill Boulanger, CEO of Obiter Research, holds a few grams of 18-MC (18-methoxycoronaridine), a synthetic ibogaine derivative that he believes can cure drug addiction.

In 2006 Ibogaine Association director Martin Polanco offered Wilkins a full-time job. She’d heard rumors that he was considering selling the clinic in the coming year, and on a whim she offered to buy the operation from him outright.

„It was one of those ‚Can I put that back in my mouth?‘ moments,“ Wilkins recounts with a laugh. „I didn’t have the money, I didn’t even have a car.“

Wilkins borrowed $3,000 from her mother for a down payment, changed the clinic’s name to Pangea Biomedics, and made monthly payments to Polanco for the next year and a half.

Having paid off the $65,000 debt, Wilkins’s first order of business was to relocate. Tijuana residents—and rehab clinics in particular—have been terrorized during Mexico’s ongoing drug war. Late last month, gunmen stormed a clinic and murdered 13 people, execution-style. (The mayhem wasn’t random; drug gangs operate such facilities as safe havens for their foot soldiers.) Wilkins’s primary concern, however, was noisy neighbors in the duplex, not narco-violence.

„We’d hear cell phones ring through the wall, and ranchero music—you’d hear everything,“ she recalls. „You’d try to go into a guided meditation and hear someone hammering a nail.“

Wilkins now rents a lavish four-bedroom home on a hill overlooking Tijuana’s upscale Playas neighborhood. Amenities include a hot tub, weight room, fireplace, and veranda with panoramic views. Safety was not overlooked: The subdivision is gated, and security guards inspect every vehicle that enters.

Stays at Pangea aren’t cheap. For the standard 10-day detox, Wilkins charges $7,500, travel not included. She employs a staff of 10, including two Mexican physicians, a paramedic, a masseuse/acupuncturist, and a chef. The chef, Wilkins’s sister, Sarah, is a recovering addict who credits ibogaine for kicking her drug dependence.

Aaron Aurand, a live-in volunteer, feels the same way.

„I did eight months of court-ordered inpatient treatment before I came here,“ says Aurand, a native of Spokane, Washington. „I got more therapy here in five days than I did in that entire time. Lots of junkies don’t want to look inside themselves. With this, you’ll get shown.“

In addition to ibogaine, Clare Wilkins emphasizes nutrition. The clinic’s pantry is mostly organic and gluten-free and boasts a cache of vitamins and supplements that patients gobble by the handful.

“The body has its own framework and can heal itself if you remove harmful substances and balance the systems. We do colon cleanses and liver cleanses even before they get the ibogaine,” Wilkins explains, pointing out that there are practical reasons for the former: “You get people who come in here—especially opiate addicts—who are clogged up.”

To date, Wilkins says, she has treated more than 300 patients. „Sixty-two percent of our clients are chronic-pain patients,“ she says. „You’re not talking IV [heroin] addicts or crack addicts. You’re talking grandmas on Oxycontin.“

Some people come for „psycho-spiritual“ purposes. Ken Wells, an environmental consultant from Santa Rosa, California, with a neatly trimmed gray mustache and wire-frame glasses, says he underwent conventional counseling for depression for 15 years before trying ibogaine as a last-ditch effort to save his crumbling marriage.

Three days after taking ibogaine for the first time, Wells compares the experience to „defragging a computer hard drive.“ He experimented with psychedelics decades ago in college but says ibogaine is like nothing else.

„It was outrageously powerful,“ Wells says. „It was like the inside of my eyeballs was an IMAX screen. It was all-encompassing, just a multitude of images, like 80,000 different TVs, all with a different channel on—just jillions of images, shapes, and colors.“

Did the experience help him find what he was looking for?

„I think I’m different,“ he says. „But I don’t know.“

It’s easier to track ibogaine’s effect on hardcore addicts. Wilkins, who keeps tabs on former clients, estimates that one out of every five stays off his or her „primary substance“ for six months or more.

Tom Kingsley Brown, an anthropologist at the University of California–San Diego who describes his area of study as „religious conversion and altered states of consciousness,“ recently began recruiting Pangea patients for an independent assessment of ibogaine’s long-term efficacy. Brown follows up monthly with opiate addicts during the year regarding their ibogaine treatment, to gauge whether their quality of life has improved.

„People I’ve interviewed at the clinic have had really good results, especially in the first month or so,“ reports Brown, who has enrolled four study subjects to date and hopes for a group of 30. „We know ibogaine interrupts the addiction in the short term, but what we’re really curious about is: Does that translate into long-term relief from drug dependence?“

Participants in Brown’s study fill out questionnaires that ask them to rate the intensity of different aspects of their trips, on a scale of one to five.

„People have been circling a lot of fours and fives,“ Brown says. „One of the things we’re trying to look at is if the intensity of the ibogaine experience correlates with treatment success. I strongly suspect there’s some sort of psychological component. I doubt it’s just a biological phenomenon.“

.

„The hallucinations are just an unfortunate side effect,“ Glick asserts, explaining that ibogaine works on the brain like a „hybrid“ of PCP and LSD. „Part of the problem is that when you go through this thing, it’s so profound you’ve got to believe it’s doing something. In part, it’s an attempt by the person who’s undergoing it to make sense of the whole thing.“

Generally speaking, Glick’s research on rats has shown that ibogaine „dampens“ the brain’s so-called reward pathway, reducing the release of neurotransmitters like dopamine, which cause the highs associated with everything from heroin to sugary foods. The compound has also been proven to increase production of GDNF, a type of protein that quells cravings, and to block the brain’s nicotinic receptors, the same spots that are stimulated by tobacco and other addictive substances. In other words, ibogaine doesn’t work in any one particular way or even on one specific part of the brain, and it’s these multiple „mechanisms of action,“ researchers say, that make it so effective for so many different types of addiction.

People who have taken ibogaine say it can have the unintended consequence of temporarily turning them off a substance other than their drug of choice. Lauren Wertheim traveled from her hometown of Omaha, Nebraska, to a rehab center called Awakening in the Dream House near Puerto Vallarta, Mexico, and used ibogaine to kick her meth habit.

„Ibogaine resets all your [tolerance] levels to zero, like you’ve never done drugs,“ she says. „Even coffee—the first cup set me off like a rocket launcher. That’s when I was like, ‚This stuff is for real.‘ “

Mash, the researcher from Miami, is convinced that ibogaine works long-term because it is stored in fat cells and processed by the liver into a metabolite called noribogaine that possesses powerful detoxifying and antidepressant properties.

„If you gave somebody LSD or psilocybin and they were coming off opiates or meth, they’d go right back out and shoot up,“ Mash says. „There’s evidence that it’s not the visions that get you drug-free; it is the ability of the metabolite to block the craving and block the signs and symptoms of opiate withdrawal and improve mood.“

Though they don’t question its effectiveness, both Mash and Glick believe it’s unlikely that ibogaine will ever be widely accepted in the United States. It’s not just that ibogaine makes people hallucinate. It can be fatal.

Since 1991, at least 19 people have died during or shortly after undergoing ibogaine therapy. Alper, the NYU professor, examined the causes of death in the fatalities, which occurred between 1991 and 2008. His findings suggest that ibogaine itself was not the culprit; the patients died because they had heart problems or combined the hallucinogen with their drug of choice. (By way of comparison, a study published last year by the Centers for Disease Control and Prevention found that between 1999 and 2006 more than 4,600 people in the United States died from overdoses involving methadone.)

„It’s knowing who to treat and who not to treat,“ Alper contends. „None of [the 19 fatalities] appear to have involved a healthy individual without pre-existing disease who didn’t use other drugs during treatment. Two deaths occurred when they took ibogaine in crude alkaloid or root-bark form—they didn’t know what they were taking or how much.“

Three of the deaths occurred at Clare Wilkins’s Tijuana clinic. She says two involved patients who had cocaine in their systems and the third victim had a pre-existing heart condition. Wilkins says she’s now more selective about her clients and requires that they undergo a drug test.

„The learning curve has been difficult at times, but people need to know this can be safe,“ Wilkins says. „We have to show people how far we’ve come.“

Some of the scientists, however, think they’ve found alternatives that will make the risks—and the tripping—associated with ibogaine unnecessary.

Mash has devised two ways to isolate the metabolite noribogaine and administer it: a pill, and a patch similar to the nicotine variety. She hopes to begin testing the products on humans by the end of this year.

„It has all the benefits without the adverse side effects—including no hallucinations,“ Mash says. „I spent a lot of years really pushing ibogaine as far as I could, both in preclinical and clinical studies. But everything that I’ve learned in the course of 18 years of working on ibogaine has convinced me that the active metabolite is the drug to be developed.“

Glick, meanwhile, teamed up with a chemist named Martin Kuehne from the University of Vermont to create and research a chemical called 18-MC (short for 18-methoxycoronaridine) that mimics ibogaine’s effect on a specific nicotinic receptor. Just like ibogaine, 18-MC appears to work wonders on drug-addicted rats.

„Cocaine, meth, nicotine, morphine—we did the same studies with 18-MC, and it worked as well or better than ibogaine,“ Glick says. „We also have data that it will be useful in treating obesity. In animals, it blocks their intake of sweet and fatty foods without affecting their nutrient intake.“

Glick and his cohorts have yet to determine whether their synthetic ibogaine has psychedelic properties. The rats, after all, aren’t talking.

„You look at an animal given ibogaine, and you can’t tell if they’re hallucinating. But they look positively strange,“ Glick says. „You give them 18-MC and you can’t really tell. But we hope when it gets to people, it won’t produce hallucinatory effects.“

The first human testing of 18-MC is scheduled to begin later this month in Brazil. But scientists there won’t be studying its effect on addiction. They’ll be investigating the drug’s potential as a cure for the parasitic infection leishmaniasis, an affliction similar to malaria that is common in tropical climates. Through pure coincidence, 18-MC is chemically similar to other drugs that are used to treat the disease.

The Americans jumped at the chance to test their product in South America. Although 18-MC has shown promise and no observable side effects in animals, not a single pharmaceutical company has shown interest in developing it as an anti-addiction product.

„We’re fortunate we have this other disease apart from addiction where we know it can be tested,“ says Kuehne, a veteran of big pharma who worked for Ciba (a predecessor of Novartis). „Pharmaceutical companies don’t like cures. Really, they don’t—that’s the sad thing. They like treatment. Something for cholesterol or high blood pressure that you [take] for years and years, every day. That’s where the profit is.“

Further complicating matters is the fact that 18-MC has proven difficult to manufacture. Obiter Research, a company based in Champaign, Illinois, that specializes in synthesizing experimental chemicals, spent nearly two years refining the process before successfully creating about 200 grams of the substance—just enough to send to Brazil to be administered to human subjects.

„Imagine a Tinkertoy Ferris wheel,“ says Bill Boulanger, Obiter’s CEO and a former chemistry professor at the University of Illinois. „It’s like taking that apart, then trying to use half of the parts to build a fire engine. Ibogaine is a natural product, and sometimes Mother Nature does a better job than the lab.“

Boulanger is convinced there’s money to be made from 18-MC. With Obiter, he plans to patent the manufacturing process and secure intellectual-property rights. He and two partners also created a separate company, Savant HWP, in hopes of eventually opening addiction clinics across the United States that administer 18-MC in conjunction with conventional rehab techniques such as 12-step programs.

“One part is resetting the trigger that’s saying, ‚Oh, I’ve got to have it,” Boulanger says. “That’s helping the people fight withdrawal, and that would be part of the whole operation. But it’s just one facet. It’s got to be holistic. Just handing out a pill and sending them on their way is a bad idea.”

The notion of hallucination-free ibogaine, however, rubs the drug’s die-hard supporters the wrong way.

„With methadone, they just removed euphoria from opiates,“ says Dimitri „Mobengo“ Mugianis. „This is the same process they’re doing now—removing psychedelic and visionary experience. Ibogaine works. What are they trying to improve or fix? It’s not broken, and they’re spending a great amount of time and money to fix it.“

A former heroin addict, Mugianis is an underground ibogaine-treatment provider. He kicked his habit with the help of ibogaine administered at Lotsof’s clinic in the Netherlands. The experience was so extraordinary that Mugianis was inspired to travel to Gabon to be initiated into the native Bwiti religion and was trained by local shamans. He says he has performed more than 400 ritualistic ceremonies on addicts, most of them in New York City hotel rooms, using ibogaine and iboga root bark.

Despite his strong belief in the power of ibogaine, Mugianis does not see it as a miracle cure for addiction.

„The 12-step approach really helped in combination with ibogaine,“ he says. „I say it interrupts the physical dependency, because that’s what it does. There’s no cure. It’s not a cure. It allows you a window of opportunity, particularly with opiate users.“

Efforts are afoot to legalize—or at least legitimize—ibogaine in the United States. Convincing doctors and elected officials to support a potent, occasionally lethal hallucinogen can be a tough sell. That pitch becomes doubly difficult when some of the ibogaine enthusiasts themselves inspire skepticism.

One of ibogaine’s most outspoken advocates is Dana Beal. An eccentric character who helped found the Youth International Party (more commonly known as the Yippies) in the 1960s, Beal sports a bushy white mustache that inspired a New York Times reporter to liken him to „a Civil War-era cavalry colonel.“ Beal travels the country giving PowerPoint presentations touting the benefits of ibogaine and medical marijuana.

In June 2008, he was arrested by police in Mattoon, Illinois, and charged with money laundering. He was carrying $150,000 in cash in two duffel bags, money he claims was going to finance an ibogaine clinic and research center in Mexico. Beal maintains his innocence and is free on bail as the case heads to trial.

It’s folks like Beal, says pharmacologist Stanley Glick, who keep ibogaine and 18-MC from being embraced by the medical mainstream.

„Some of my colleagues, as well as funding agencies, lump us together without really considering the data,“ Glick says. „There’s a lot of baggage that comes with ibogaine, some of it warranted, some of it unwarranted. It’s really a stigma. Drug abuse itself has a stigma, and unfortunately so does ibogaine. It has really hurt the science

Beal shrugs off the criticism, arguing that grassroots activism is the only way to ensure that politicians will endorse ibogaine. Besides, he adds, the government stopped funding ibogaine research long before he was arrested.

„[The scientists] think if they stay away from us activists, NIDA will bless them,“ says the self-styled rabble-rouser. „NIDA is not blessing them. They’re washed up and on a strange beach. How will they get FDA-approved clinical trials without activists? Explain to me a way that works, and I will do it.“

Beal jokes that the best advertisement for ibogaine might be an episode from the 11th season of Law & Order: Special Victims Unit in which a heroin addict who needs to testify in court is administered ibogaine to make his withdrawal symptoms disappear overnight. “Maybe Congress will watch SVU and say, ‚Maybe we should check this out—wow!—it works for methamphetamine, too?’” he says sarcastically.

In truth, ibogaine’s effectiveness against meth has already helped it gain acceptance abroad. Lawmakers in New Zealand, where methamphetamine use has skyrocketed in recent years, recently tweaked the nation’s laws to allow physicians to prescribe ibogaine. Dr. Gavin Cape, an addiction specialist at New Zealand’s Dunedin School of Medicine, says the nation’s doctors are so far reluctant to wield their new anti-meth weapon.

„[There are] no true controlled studies to give evidence as to its safety and effectiveness,“ Cape says. „There is a strong advocacy group [in New Zealand] for ibogaine, and it may turn out to have a place alongside conventional therapies for the addictions, but I’m afraid we are a few years away from that goal.“

Last month, dozens of ibogaine researchers, activists, and treatment providers gathered for a conference in Barcelona, where topics included safety and sustainable sourcing of ibogaine from Africa. Dr. Kenneth Alper was among the attendees who gave a presentation on the benefits of ibogaine to the Catalan Ministry of Health. The NYU prof believes ibogaine’s most likely path to prominence in the United States will be as a medication for meth addiction, for the simple reason that doctors and treatment providers have found that small daily—and thus drug-company-friendly—doses seem to work better for meth addiction than the mind-blowing „flood doses“ used on opiate addicts.

Alper says no one thought to try non-hallucinogenic quantities of ibogaine until recently. Ibogaine treatment providers tend to have been former ibogaine users, and most assumed that the introspection brought on by tripping was key to overcoming their addictions. „That’s just how it evolved,“ he says, noting that the large doses do seem to work best for opiate detox. „You’re talking about a drug that has been used in less than 10,000 people in the world in terms of treatment. It’s not surprising that’s how it evolved.“

„The visions have some psychological content that is salient and meaningful,“ Alper adds. „On the other hand, there is no successful treatment for addiction that’s not interpreted as a spiritual transformation by the people who use it. It’s the G-word. It’s God. We as physicians don’t venture into that territory, but most people do.“

source: http://www.villagevoice.com/2010-11-17/news/ibogaine-hallucingen-heroin/6/

TEHRAN (FNA)- Commander of the anti-narcotic squad of Iran’s Law Enforcement Police General Hamid Reza Hossein-Abadi announced that Iranian forces have seized 240 tons of narcotics during the last 7 months.

„Over 240 tons of different types of narcotics have been discovered throughout the country since the beginning of the current (Iranian) year (March 21, 2010),“ Hossein-Abadi said in Iran’s Northwestern city of Orumiyeh on Saturday evening.

„Seizures included 14 tons of heroin, 2 tons of morphine, 185 tons of opium, 28 tons of hashish as well as other types of narcotics,“ the commander announced.

As regards synthetic drugs, the commander said that 617 kg of Crystal (Methamphetamine) was also seized during the period, adding that seizures of synthetic drugs show a 17% increase compared with the same period last year.

Methamphetamine, a synthetic drug with more rapid and lasting effects than amphetamine, is illegally used as a stimulant. The drug has recently been smuggled and distributed in Iran by drug-traffickers who seek to change addiction behaviors in the country and redirect addicts‘ tendency from conventional drugs, such as opium, heroin and hashish, to those narcotics mostly prevalent in the West, like cocaine, crack, crystal and LSD.

Hossein-Abadi also noted that police have disbanded 941 rings involved in drug-trafficking activities throughout the country and arrested 130, 000 drug dealers during the last 7 months.

Iran leads international efforts in fighting drug networks and narcotic traffickers. According to the statistical figures released by the UN, Iran ranks first among the world countries in preventing entry of drugs and decreasing demand for narcotics.

The United Nations credits Iran with the seizure of 80 percent of the opium netted around the world.

Iran lies on a major drug route between Afghanistan and Europe, as well as the Persian Gulf states. Since the 1979 Islamic Revolution, the Iranian police have lost more than 3700 of their personnel in the country’s combat against narcotics.

Eastern Iran borders Afghanistan, which is the world’s number one opium and drug producer. Iran’s geographical position has made the country a favorite transit corridor for drug traffickers who intend to smuggle their cargoes from Afghanistan to drug dealers in Europe.

Each year, the Iranian government spends hundreds of millions of dollars erecting barriers along the borders with Pakistan and Afghanistan and pumping resources into checkpoints. Officials said the battle against drug addiction and trafficking costs Iran US$1 billion a year.

ccurate monitoring of opium poppy production in Afghanistan – responsible for 90% of the world’s supply of the illegal crop – has become increasingly difficult with rising security concerns, but remote sensing survey techniques developed by Cranfield University have proved critical in providing accurate information to inform UK and international policy and counter-narcotics actions in Afghanistan.

As a lead nation on counter-narcotics policy formulation and providing support to the Government of Afghanistan, the UK has a particular interest in opium poppy control in Afghanistan, which is said to supply almost all heroin consumption in the UK.

In 2003, it was identified that the quantitative information about the trends and production of opium gathered annually by both the UN Office on Drugs and Crime (UNODC) and the US Government were different and often contradictory. Cranfield University was tasked by the UK Government with undertaking an independent review of the survey techniques employed at the time. From 2005 to 2009 this included conducting full scale poppy cultivation surveys in key provinces to study differences in their approaches. This research was used to promote technical discussions between survey teams and recommend changes to survey methodologies.  From 2007 this included remote sensing based verification of the success of poppy eradication schemes undertaken as part of the Government of Afghanistan’s National Drug Control Strategy.

Cranfield initially employed aerial remote sensing techniques using high resolution digital imagery to map poppy and cereal fields and measure the extent of eradicated poppy fields. However, on-going security issues prevented flying over key areas where poppy fields were planted. Cranfield therefore evolved alternative methods using high resolution satellite imagery integrated with medium resolution imagery from the Disaster Monitoring Constellation (DMC) satellites and streamlined their methods based on the timing of poppy flowering to optimise imagery acquisition. Resulting reports were available much earlier than in previous years, and were much more detailed at district level, providing invaluable data for policy development and targeted action.

In 2009, Cranfield’s research identified a 37% reduction in poppy cultivation where wheat seed and fertiliser were distributed by provincial authorities in the central areas of Helmand province. Outside these areas poppy cultivation in Helmand increased by eight percent.  These figures were cited by major counter-narcotics stakeholders including the UK Prime Minister, US Department of State and the executive director of the UNODC.

The University has continued working with the UNODC in developing survey methodology, capacity building and mentoring Afghan nationals to enable them to undertake key remote sensing techniques themselves.

source: http://www.environmental-expert.com/STSE_resultEach.aspx?cid=6363&idprofile=7082

“Der Bericht unterstreicht die Notwendigkeit eines aktiven Gesundheits-, Jugend- und Verbrauchschutzes auf der Basis einer akzeptierenden Drogenpolitik. Er enthält jedoch auch einige blinde Flecken”, erklärt der drogenpolitische Sprecher der Fraktion DIE LINKE, Frank Tempel, zur Veröffentlichung des Jahresberichts 2009 der deutschen und europäischen Beobachtungsstelle für Drogen und Drogensucht. Tempel weiter:

“Im Bericht finden sich keinerlei Hinweise auf die Problematik der Streckmittel in den illegalisierten Drogen Cannabis, Speed, Heroin und Ecstasy. Dabei handelt es sich um ein ernstzunehmendes Problem. Cannabis etwa wurde im letzten Jahr von rund 23 Millionen EU-Bürgern konsumiert. Aufgrund der Illegalität ist der Drogenmarkt jedoch weiterhin in der Hand international tätiger krimineller Strukturen, für deren Bekämpfung Deutschland und die Europäische Union jedes Jahr Millionen ausgeben. Die Entkriminalisierung und Legalisierung von Cannabis würde dafür sorgen, dass diese Gelder für die dringend notwendige Präventionsarbeit zur Verfügung gestellt werden könnten. Eine akzeptierende Drogenpolitik würde zudem die Ergebnisse der Suchtbekämpfung verbessern, denn ein aufgeklärter und bewusster Umgang mit Drogen verringert nachweislich die Gesundheitsgefahren ( z.B. Suchtgefahr) für die Konsumenten. An erster Stelle sollte dabei allerdings eine legale Droge stehen: Alkohol.

Es ist skandalös, dass ausgerechnet die Drogenbeauftragte der Bundesregierung, Mechthild Dyckmans (FDP), keine Notwendigkeit für einen eigenen Drogenbericht für das Jahr 2009 sieht. Ihre Begründung, die Ergebnisse für 2009 hätten lediglich Auskunft über die Drogenpolitik der letzten Bundesregierung gegeben, ist absurd. Eine langfristige Beobachtung der Drogenkonsumsituation in Deutschland ist unerlässlich.”

F.d.R. Christian Posselt

quelle: http://www.artikel-presse.de/?p=251693

Den Bericht gibt es hier als download, 3 Postings bevor oder hier: http://wp.me/pIQTX-kF

Fast jeder Zehnte der 18- bis 39-Jährigen hat im vergangenen Jahr mindestens einmal eine illegale Droge genommen. Dies geht aus dem Jahresbericht der Deutschen Beobachtungsstelle für Drogen und Drogensucht (DBDD) hervor. Etwa jeder fünfte Drogenkonsument, der sich in Europa in Behandlung gibt, ist jedoch inzwischen älter als 40, in manchen Ländern ist es fast jeder dritte, heißt es im Jahresbericht der EU-Drogenbeobachtungsstelle. Ein Grund hierfür sei die «Heroin-Epidemie» der 1980er-Jahre. In dieser Zeit wurden viele Jugendliche abhängig, die nun körperlich deutlich gealtert sind – mit den entsprechenden Folgekosten für die Gesundheitssysteme. Die Behandlung von Älteren sei teuer, weil sie besondere Therapien benötigten. «Ein 40-jähriger Heroinabhängiger braucht eine Behandlung wie ein 60-Jähriger, weil sein Körper so schnell gealtert ist», sagte der Leiter der EU-Drogenbeobachtungsstelle, Wolfgang Götz. Viele hätten eine lange Drogenkarriere mit Entzug und Gefängnis hinter sich. Oft seien sie mit HIV oder Hepatitis infiziert und alkoholabhängig. «Da reicht es nicht, eine Ersatzsubstanz zu geben», sagte Götz. «Da ist die Geriatrie gefragt.»

Am weitesten verbreitet ist bei den 18- bis 39-Jährigen Cannabis. Mit 9,3 Prozent liegt der Wert für 2009 um 0,1 Punkte höher als bei der letzten Erhebung 2006. «Die Verbreitung illegaler Drogen scheint aber insgesamt nicht zu steigen», sagte DBDD-Leiter Tim Pfeiffer- Gerschel. In Deutschland kamen 1331 Menschen durch den Konsum illegaler Drogen ums Leben. Das ist ein Rückgang um 8 Prozent im Vergleich zu 2008. Das Durchschnittsalter eines Drogentoten beträgt Pfeiffer-Gerschel zufolge 36 Jahre.

An erster Stelle des europaweiten Drogenkonsums steht nach wie vor Cannabis, mit dem sich jährlich etwa 23 Millionen Menschen berauschen. Der Konsum sei aber rückläufig. Rund 14 Millionen Europäer nehmen Cocain, zwei Millionen Amphetamine. Die Bundesdrogenbeauftragte Mechthild Dyckmans zeigte sich vor allem zufrieden mit den Konsumzahlen von Cocain, die in Deutschland «vergleichsweise niedrig» seien. Sie forderte, insbesondere die Verbreitung neuer synthetischer Drogen aufmerksam zu beobachten.

 

quelle:http://www.pharmazeutische-zeitung.de/index.php?id=35922

Million plus in Europe’s 60s generation of ageing drug addicts, report finds

122,000 heroin and crack users aged 35-64 in Britain

    Three lines of coke and razor
    More older people than ever are experiencing problems with drug addiction. Photograph: Lester Lefkowitz/Corbis

    Keith Richards and Ozzy Osbourne may now be clean, but there are a hidden generation of ageing heroin users in their 50s and 60s who have not been able to kick the habit.

    The European drugs agency say there are more than a million problem drug users aged over 40 across the EU, including 122,000 in Britain, who dent the widely held perception that drug use is a youth phenomenon.

    „In reality, more older people than ever are reporting experience with drugs at some point in their lives and drug problems have no age limits,“ said the annual report of the European monitoring centre for drugs and drug addiction, published today.

    The agency says about a million people across Europe aged 45 to 64 have used cannabis alone in the last year. While they have not „matured out“ of drug use, this is far below levels in the US where nearly 10% of the 50 to 59 age group — the 60s generation — regularly use cannabis.

    There is a further group of nearly a million older problem drug users, including 122,000 in Britain aged between 35 and 64 who use heroin and crack, who first became dependent in the 1980s and 1990s. Many have tried detox and methadone substitution but have not managed to stop.

    Wolfgang Götz, director of the agency, said that while the Rolling Stone, Keith Richards, says he is clean, many older drug users face a life of repeated overdoses with chronic health implications. They are prematurely experiencing the health problems faced by people 20 years older. Denmark and Germany are among countries developing specialist nursing or retirement homes for older drug users .

    source: http://www.guardian.co.uk/society/2010/nov/10/europe-heroin-users-ageing

EITHNE DONNELLAN

TEENAGERS WHO smoke heroin thinking it is safer than injecting the drug are now presenting with chronic lung disease, a conference in Dublin heard yesterday.

Several young people, one of them just 18 years old, have presented at the emergency department of the Mater hospital with lungs one would expect to see in a “70-year-old who had been smoking all their lives”.

Rosaleen Reilly, a respiratory nurse at the hospital, presented her findings at the annual conference of the National Council for the Professional Development of Nursing and Midwifery. She said the patients presented with what were akin to asthma attacks, but did not respond to asthma treatment quickly. Their symptoms were similar to those seen in older people with chronic obstructive pulmonary disease, she said.

In her study, one male aged 18 who smoked up to 20 bags of heroin a day since his early teens first presented with respiratory distress in November 2008. He now has emphysema.

source: http://www.irishtimes.com/newspaper/ireland/2010/1111/1224283092985.html

Summary:

The report on the state of the drugs problem in Europe presents the EMCDDA’s yearly overview of the drug phenomenon. This is an essential reference book for policymakers, specialists and practitioners in the drugs field or indeed anyone seeking the latest findings on drugs in Europe. Published every autumn, the report contains non-confidential data supported by an extensive range of figures.

Download as pdf (2.97 MB):

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Patients on opioid replacement therapy have an increased risk of death early on in treatment, and again when they come off, researchers have found.

The risk was greatest — eight to nine times as high as that during treatment — immediately after coming off methadone or buprenorphine, Matthew Hickman, MD, of the University of Bristol in England, and colleagues reported in BMJ.

„The overall risk of death during opiate substitution treatment was lower than the risk of death out of treatment,“ they wrote.

The researchers conducted a prospective cohort study among primary care patients diagnosed with substance abuse and prescribed methadone or buprenorphine between 1990 and 2005.

A total of 5,577 patients given 267,003 prescriptions were followed up until one year after the expiration date of their last prescription.

Overall, the researchers found that the crude mortality rates were almost double for those who came off treatment: 0.7 per 100 person-years while on treatment and 1.3 per 100 person-years after coming off.

However, in the first two weeks of opiate substitution, the crude mortality rate was 1.7 per 100 person-years — just over three times higher than the rate during the rest of the time on treatment, the researchers said.

The first two weeks was a critical time period after treatment was stopped, too. Crude mortality rates were 4.8 per 100 person-years during the first two weeks post-treatment and 4.3 per 100 person-years during the third and fourth weeks.

That’s nine and eight times the risk of death when being on treatment, the researchers said.

Those rates fell to 0.95 during the rest of the time off treatment — a figure that was still nearly twice as high as patients‘ baseline risk.

The researchers said they were cautious about the potential mechanisms at work because they didn’t directly assess those factors in this study.

But, they said, the findings are generally consistent with the literature, which holds that risk of overdose is higher when opiate tolerance has temporarily fallen — after a patient has gone through an induction phase to start treatment, for instance.

So if, after ending replacement therapy, the patient goes back to using his drug of choice, „the first few occasions of opiate use pose the greatest risk of precipitating fatal overdose before tolerance has been re-established,“ according to the researchers.

They also observed that substitution therapy’s mortality benefits may relate to the duration of treatment, as opiate substitution treatment has more than an 85% chance of reducing overall mortality if patients are on it for at least 12 months.

They said that further research is needed to investigate the effect of average duration of opiate substitution treatment on drug-related mortality.

They also called for closer supervision of the induction phase of treatment, and for ongoing monitoring of the impact of opiate substitution treatment on mortality in the U.K. and other countries.

 

source: http://www.medpagetoday.com/Psychiatry/Addictions/23014

Peter Dale Scott

This Chapter 3 from my newly published American War Machine describes America’s Operation Paper, a November 1950 program to arm and supply the Kuomintang remnant troops of General Li Mi in Burma. Operation Paper itself was relatively short-lived, but it had two long-term consequences that have not been adequately discussed.

The first is that the CIA was launched into its fifty-year history of indirectly facilitating and overseeing forces engaged in vastly expanding the production of opiates, in successive areas not previously major in the international traffic. This is a history that stretches, almost continuously, from Thailand and Burma through Laos until the 1970s, and then to present-day Afghanistan.

The second is that the resulting drug proceeds helped supplement the CIA’s efforts to develop its own Asian proxy armies, initially defensive but increasingly offensive. This led in 1959 to the initiation of armed conflict in the previously neutral and Buddhist nation of Laos, an unwinnable hot war that soon spread to Vietnam.

The decision to launch Operation Paper was made by a small cabal inside the Office of Policy Coordination (OPC), notably Desmond Fitzgerald and Richard Stilwell in conjunction with former OSS Chief William Donovan, who favored the rollback of communism over the official State Department policy of containment. My book sees the expanding offensive efforts in Southeast Asia, after switching from Li Mi’s forces to the CIA’s Thai proxy army PARU, as a watershed in the conversion of America’s post-war defense establishment, which was concerned above all with preserving the status quo in western Europe, into today’s offensive American War Machine, with actions centered on Southeast and Central Asia.

The writing of American War Machine has given me a clearer picture of America’s overall responsibility for the huge increases in global drug trafficking since World War II. This is exemplified by the more than doubling of Afghan opium drug production since the U.S. invaded that country in 2001. But the U.S. responsibility for the present dominant role of Afghanistan in the global heroin traffic has merely replicated what had happened earlier in Burma, Thailand, and Laos between the late 1940s and the 1970s. These countries also only became factors in the international drug traffic as a result of CIA assistance (after the French, in the case of Laos) to what would otherwise have been only local traffickers. •

It is not too much to conclude that, for such larger reasons of policy, U.S. authorities actually suborned at times an increase of illicit heroin traffic.

An understanding of this phenomenon must inform future scholarly work on drug trafficking in Asia.1

If opium could be useful in achieving victory, the pattern was clear. We would use opium.2

Thailand and Drugs: A Personal Preface

It is now clearly established that in November 1950, President Truman, faced with large numbers of Chinese communist troops pouring into Korea, approved an operation, code-named Operation Paper, to prepare remnant Kuomintang (KMT) forces in Burma for a countervailing invasion of Yunnan. It is clear also that these troops, the so-called 93rd Division under KMT General Li Mi, were already involved in drug trafficking. It is clear finally that, as we shall see, Truman belatedly approved a supply operation to drug traffickers that had already been in existence for some time.

The purpose of this chapter is to explore the process that led up to Truman’s validation of a program to use drug proxies in Burma. It will be an exercise in deep history, raising questions that the archival records presently available cannot definitively answer. Some of most relevant records, chiefly those of the Office of Policy Coordination (OPC) that initiated Operation Paper, are still closed to public view. Others, such as those of the World Commerce Corporation (WCC) or of the Willis Bird import-export firm in Bangkok, would probably tell us little even if we had them. And some of the most important events, such as the path by which Thai Opium Monopoly opium soon reached the streets of Boston, were probably never documented at all.

The topic of this chapter is a major one in the postwar history of China, Southeast Asia, and the global drug traffic. With needed U.S. support, above all in the form of airlift and arms, Li Mi’s irregulars were soon marketing, in the words of their U.S. overseer Richard Stilwell (chief of OPC Far East), “almost a third of the world’s opium supply.”3 Burton Hersh, who transmits Stilwell’s comment, adds his own remark that Li Mi’s troops “developed over time into an important commercial asset for the CIA.” Based on what is currently known, I would express the relationship differently: Li Mi’s drug-trafficking troops continued to be of major importance to the CIA—but as self-supporting, off-the-books allies in the struggle to secure Southeast Asia against communist advances, not as a source of income for the CIA itself.

Overview

In the 1950s, after World War II, the chances seemed greater than ever before for a more peaceful, orderly, legal, and open world. Even the world’s two great superpowers, the United States and the Soviet Union, had agreed on rules and procedures for mediating their serious differences through a neutral body, the United Nations. The United States was then wealthy enough to finance postwar reconstruction in devastated Europe and later fund international programs in fields such as health and agriculture in the newly liberated former colonies of the Third World.

But the United Nations was not destined to remain the theater for the resolution of international conflict. One major reason for this was that the Soviet Union, the United States, and then, after 1949, China all pursued covert policies, low key at first, that brought them increasingly into conflict and proxy war.

The Marxist-Leninist nations of the Soviet Union and China lent support to other Marxist-Leninist parties and movements, some of them insurrectionary, in other parts of the world. Washington’s often inaccurate perception saw these parties and movements as proxies for Soviet and/or Chinese power. Thus, much of the Cold War came to be fought covertly in areas, like Southeast Asia, about which both the United States and the Soviet Union were stunningly ignorant.

From the very beginning of the postwar era, Washington looked for proxies of its own to combat the threat it perceived of world revolution. Some of these proxies are now virtually forgotten, such as the Ukrainian guerrillas, originally organized by Hitler’s SS, who fought an OPC-backed losing battle against Russia into the early 1950s. Some, like the mafias in Italy and Marseille, soon outgrew their U.S. support to become de facto regional players in their own right.

But one of America’s early proxy armies, the remnants of Nationalist Chinese KMT forces in Burma and later Thailand, would continue to receive U.S. support into the 1960s. Like the mafias in Europe and the yakuza in Japan, these drug proxies had the advantage for secrecy of being off-the-books assets, largely self-supporting through their drug dealing, and firmly anticommunist.

The OPC and CIA’s initial support of this program, by reestablishing a major drug traffic out of Southeast Asia, helped institutionalize what became a CIA habit of turning to drug-supported off-the-books assets for fighting wars wherever there appeared to be a threat to America’s access to oil and other resources—in Indochina from the 1950s through the 1970s, in Afghanistan and Central America in the 1980s, in Colombia in the 1990s, and again in Afghanistan in 2001.7

Harvesting opium in Karenni state, Burma

The use of drug proxies, at odds with Washington’s official antidrug policies, had to remain secret. This meant that in practice major programs with long-term consequences were initiated and administered by small cliques with U.S. intelligence ties that were almost invisible in Washington and still less visible to the American people. These cliques of like-minded individuals, at ease in working with traffickers and other criminals, were in turn part of a cabal supported by elite groups at high levels.

The U.S. use of the drug traffic from the KMT troops in Burma had momentous consequences for the whole of Southeast Asia. For the OPC infrastructure for the KMT troops (Sea Supply Inc., see below) was expanded and modified, with support from William Donovan and Allen Dulles, to develop and support an indigenous guerrilla force in Thailand, PARU. PARU, far less publicized than the KMT troops, did as much or more to influence U.S. history. For PARU’s success in helping to guarantee the independence of Thailand encouraged the United States in the 1960s to use PARU in Laos and Vietnam as well. Thus, PARU’s early successes led the United States, incrementally, into first covert and eventually overt warfare in Laos and Vietnam. We shall see that, according to its American organizer James William [“Bill”] Lair, PARU, like the KMT forces, was in its early stage at least partly financed by drugs.

In short, some Americans had a predictable and almost continuous habit of turning to the drug traffic for off-the-books assets. This recourse began as a curious exception to the larger U.S. policy of seeking political resolution of international conflicts through the United Nations. It also pitted the regular U.S. diplomats of the State Department against the Cold Warriors of the secret agency, OPC, that had these drug assets at its disposal. This was not the only time that a small U.S. bureaucratic cabal, facing internal opposition but enjoying high-level backing, could launch an operation that became far larger than originally authorized. The pattern was repeated, with remarkable similarities, in Afghanistan in 1979. Once again, as in Thailand, the original stated goal was the defense of the local nation and the containment of the communist troops threatening to subdue it. Once again this goal was achieved. But once again the success of the initial defensive campaign created a momentum for expansion into a campaign of offensive rollback that led to our present unpromising confrontation with more and more elements of Islam.8

The cumulative history of these U.S. interventions, both defensive (successful) and offensive (catastrophic), has built and still builds on itself. Successes are seen as opportunities to move forward: it is hard for mediocre minds not to draw bad lessons from them. Failures (as in Vietnam) are remembered even more vividly as reasons to prove that one is not a loser.

It is thus important to analyze this recurring pattern of success leading to costly failure, to free ourselves from it. For it is clear that the price of imperial overstretch has been increasing over time.

With this end in mind, I shall now explore key moments in the off-the-books story of Southeast Asian drug proxies and the cliques that have managed them, a trail that leads from Thailand after World War II to the U.S. occupations of Iraq and Afghanistan today.

The Origins of the CIA Drug Connection in Thailand

To understand the CIA’s involvement in the Southeast Asian drug traffic after World War II, one must go back to nineteenth-century opium policies of the British Empire. Siamese government efforts to prohibit the smoking of opium ended in 1852, when King Mongkut (Rama IV), bowing to British pressures, established a Royal Opium Franchise, which was then farmed out to Siamese Chinese.9 Three years later, under the terms of the unequal Bowring Treaty, Siam accepted British opium free of duty, with the proviso that it was to be sold only to the Royal Franchise. (A year later, in 1856, a similar agreement was negotiated with the United States.) The opium farm became a source of wealth and power to the royal government and also to the Chinese secret societies or triads that operated it. Opium dependency also had the effect of easing Siam into the ways of Western capitalism by bringing “peasants into the cash economy as modern consumers.”10

Until it was finally abolished in 1959, proceeds from the Opium Franchise (as in other parts of Southeast Asia) provided up to 20 percent of Siamese government revenue.11 This is one reason why the opium franchise ceased to be farmed out to Chinese businessmen in 1907 and became (as again in other parts of Southeast Asia) a government monopoly. Another was the desire to reduce the influence of Chinese secret societies and encourage Chinese assimilation into Siam. As a result, the power of the secret societies did generally decline in the twentieth century, except for a revival under the Japanese occupation during World War II. By this time the KMT, operating under cover, was the most powerful force in the Bangkok Chinese community, with overlapping links to Tai Li’s KMT intelligence network and also the drug traffic.12

Although the official source of opium for the Siamese franchise was India, the relatively high cost of Indian opium encouraged more and more smuggling of opium from the Shan states of eastern Burma. With the gradual outlawing of the opium traffic in the early twentieth century, the British banned the use of Shan opium inside Burma but continued to tax the Shan states as before. In this way the British tacitly encouraged the export of Shan opium to the Thai market.13

When Thailand declared war against Britain in January 1942, Shan opium became the only source for the lucrative monopoly. This helps explain the 1942 invasion of the opium-producing Shan states by the Thai Northern (Prayap) army, in parallel to the Japanese expulsion of the British from Burma.14 In January 1943, as it became clearer that Japan would not win the war, the Thai premier Phibun Songkhram used the Northern Army in Kengtung, with its control of Shan opium, to open relations with the Chinese armies they had been fighting, which had by now retreated across the Yunnan–Burma frontier.15 One of these was the 93rd Division, at Meng Hai in the Thai Lü district of Sipsongphanna (Xishuangbanna) in Yunnan.16 The two sides, both engaged in the same lucrative opium traffic, quickly agreed to cease hostilities. (According to an Office of Strategic Services [OSS] observer, the warlord generals of Yunnan, Lung Yun, and his cousin Lu Han, commander of the 93rd Division, were busy smuggling opium from Yunnan across the border into Burma and Thailand.17)

An OSS team of Seri Thai (Free Thais), led by Lieutenant Colonel Khap Kunchon (Kharb Kunjara) and ostensibly under the direction of OSS Kunming, made contact with both sides in March–April 1944.18 When Khap arrived at the 93rd Division Headquarters, “he discovered that an informal ceasefire had been observed along the border between southern Yunnan and the Shan States [in Burma] since early 1943 with the arrangement being cemented from time to time by gifts of Thai whisky, cigarettes and guns presented to officers of the 93rd Division by their Thai counterparts.”19

Khap, with the permission of his OSS superior Nicol Smith, sent a message from Menghai to a former student of his now with the Thai Northern Army in Kengtung.20 “The letter stressed the need for Thai forces to switch sides at the appropriate moment and asked for the names of Thai officers in the area who would be willing to cooperate with the Allies.”21 Khap’s letter, with its apparent OSS endorsement, reached Phibun in Bangkok and led to an uninterrupted postwar collaboration between the Northern Army and the 93rd Division.22

Khap, however, was a controversial figure inside OSS, mistrusted above all for his dealings with Tai Li. We learn from Reynolds’s well-documented history that Tai Li and Khap, in conjunction with the original OSS China chief Milton Miles, had been concertedly pushing a plan to turn the Thai Northern Army against the Japanese.23 But John Coughlin, Miles’s successor as OSS chief in China, consulted some months later with Donovan in Washington and expressed doubts about the scheme. A follow-up memo to Donovan questioned Khap’s motives:

I . . . doubt that he can be trusted. . . . I feel that he will make deals with Tai Li of which I will not be informed. . . . I am at a loss to figure out Tai Li’s extreme interest in him, unless there is some agreement between them that I know nothing about.24

Like his sources, Reynolds’s archival history is tactfully silent on the topic of opium. But Tai Li’s opium connection to the KMT in Thailand and Burma was well known to OSS and may well have been on Coughlin’s mind.25

KMT forces in Burma, 1953

The Northern Army–93rd Division–KMT connection had enormous consequences. For the next three decades, Shan opium would be the source of revenue and power for the KMT in Burma and both the KMT and the Northern Army in Bangkok. All of Thailand’s military leaders between 1947 and 1975—Phin Chunhawan, his son-in-law Phao Sriyanon, Sarit Thanarat, Thanom Kittikachorn, Prapat Charusathien, and Kriangsak Chomanand—were officers from the Northern Army. Successively their regimes dominated and profited from the opium supplied by the KMT 93rd Division that after the war reestablished itself in Burma.26 This was true from the military coup in Bangkok of November 1947 until Kriangsak’s resignation in 1980.27 A series of coups d’état—in 1947, 1951, 1957, and 1975—can be analyzed in part as conflicts over control of the drug trade.28

As in Indonesia and other Asian countries, the generals’ business affairs were handled by local Chinese. The Chinese banking partner of Phin Chunhawan and Phao Sriyanon was Chin Sophonpanich, a member of the Free Thai movement who in the postwar years enabled Phao to die as “one of the richest men in the world.”29 When in 1957 Sarit displaced Phao and took over both the government and the drug trade, both Phao and Chin had to flee the country.30

The United States Helps Rebuild the Postwar Drug Connection

To appreciate the significance of the connection we are discussing, we must keep in mind that, by 1956, the KMT had been driven from the Chinese mainland and that Chinese production of opium, even in remote mountainous Yunnan, had been virtually eliminated. The disruptions of a world war and revolution had created an opportunity to terminate the opium problem in the Far East. Instead, U.S. covert support for the Thai and KMT drug traffickers converted Southeast Asia, for more than two decades, into the world’s major source of opium and heroin.

The origins of the U.S. interface with these drug traffickers in Thailand and Burma are obscure. They appear, however, to have involved principally four men: William Donovan; his British ally Sir William Stephenson, the organizer with Donovan of the World Commerce Corporation (WCC); Paul Helliwell; and Willis Bird (both veterans of OSS China). After World War II, Sir William Stephenson’s WCC “became very active in Bangkok,” and Stephenson himself established a strong personal relationship with King Rama IX.31

Stephenson recruited James Thompson, the last OSS commander in Bangkok, to stay on in Bangkok as the local WCC representative. This led to the WCC’s financing of Thompson’s Thai Silk Company, a successful commercial enterprise that also covered Thompson’s repeated trips to the northeastern Thai border with Laos, the so-called Isan, where communist insurrection was most feared and where future CIA operations would be concentrated.32 One would like to know whether WCC similarly launched the import-export business of Willis Bird, of whom much more shortly.

In the same postwar period, Paul Helliwell, who earlier had been OSS chief of Special Intelligence in Kunming, Yunnan, served as Far East Division chief of the Strategic Service Unit, the successor organization to OSS.33 In this capacity he allegedly “became the man who controlled the pipe-line of covert funds for secret operations throughout East Asia after the war.”34 Eventually, Helliwell would be responsible for the incorporation in America of the CIA proprietaries, Sea Supply Inc. and Civil Air Transport (CAT) Inc. (later Air America), which would provide support to both Phao Sriyanon of the Northern Army in Thailand and the KMT drug camps in Burma. It is unclear what he did before the creation of OPC in 1948. Speculation abounds as to the original source of funds available to Helliwell in this earlier period, ranging from the following:

1.  The deep pockets of the overworld figures in the WCC. Citing Daniel Harkins, a former USG investigator, John Loftus and Mark Aarons claimed that Nazi money, laundered and manipulated by Allen Dulles and Sir William Stephenson through the WCC, reached Thailand after the war. When Harkins informed Congress, he “was suddenly fired and sent back [from Thailand] to the United States on the next ship.”35

2.  The looted gold and other resources collected by Admiral Yamashita and others in Japan36 or of the SS in Germany.

3.  The drug trade itself. Further research is needed to establish when the financial world of Paul Helliwell began to overlap with that of Meyer Lansky and the underworld. The banks discussed in the chapter 7, which are outward signs of this connection (Miami National Bank and Bank of Perrine), were not established until a decade or more later. Still to be established is whether the Eastern Development Company represented by Helliwell was the firm of this name that in the 1940s cooperated with Lansky and others in the supply of arms to the nascent state of Israel.37

Of these the best available evidence points tentatively to Nazi gold. We shall see that Helliwell acquired a banking partner in Florida, E. P. Barry, who had been the postwar head of OSS Counterintelligence (X-2) in Vienna, which oversaw the recovery of SS gold in Operation Safehaven.38 And it is not questioned that in December 1947 the National Security Council (NSC) created a Special Procedures Group “that, among other things, laundered over $10 million in captured Axis funds to influence the [Italian] election [of 1948].”39 Note that this authorization was before NSC 10/2 of June 18, 1948, first funded covert operations under what soon became OPC.

What matters is that, for some time before the first known official U.S. authorizations in 1949–1950, funds were reaching Helliwell’s former OSS China ally Willis Bird in Bangkok. There Bird ran a trading company supplying arms and materiel to Phin Chunhawan and Phin’s son-in-law, Phao Sriyanon, who in 1950 became director-general of the Thai Police Department. By 1951 OPC funds for Bird were being handled by a CIA proprietary firm, Sea Supply Inc., which had been incorporated by Paul Helliwell in his civilian capacity as a lawyer in Miami. As noted earlier, Helliwell also became general counsel for the Miami bank that Meyer Lansky allegedly used to launder proceeds from the Asian drug traffic.

Some sources claim that in the 1940s, Donovan, whose link to the WCC was by 1946 his only known intelligence connection, also visited Bangkok.40 Stephenson’s biographer, William Stevenson, writes that because MacArthur had cut Donovan out of the Pacific during World War II, Donovan “therefore turned Siam [i.e., Thailand] into a base from which to run [postwar] secret operations against the new Soviet threat in Asia.”41

William Walker agrees that by 1947–1948, the United States increasingly defined for Thailand a place in Western strategic policy in the early cold war. Among those who kept close watch over events were William J. Donovan, wartime head of the OSS, and Willis H. Bird, who worked with the OSS in China. . . . After the war, Bird, . . . still a reserve colonel in military intelligence, ran an import-export house in Bangkok. Following the November [1947 Thailand coup] Bird . . . implored Donovan: “Should there be any agency that is trying to take the place of O.S.S., . . . please have them get in touch with us as soon as possible. By the time Phibun returned as Prime Minister, Donovan was telling the Pentagon and the State Department that Bird was a reliable source whose information about growing Soviet activities in Thailand were credible.42

Bird’s wishes were soon answered by NSC 10/2 of June 18, 1948, which created the OPC. Washington swiftly agreed that Thailand would play an important role as a frontline ally in the Cold War. In 1948, U.S. intelligence units began arming and training a separate army under General Phao, which became known as the Thai Border Police (BPP). The relationship was cemented in 1949 as the communists captured power in China. The generals demonstrated their anticommunist credentials by echoing U.S. propaganda and killing alleged leftists. At midyear a CIA [OPC] team arrived in Bangkok to train the BPP for covert support of the Kuomintang in its continuing war against the Chinese communists on the Burma-China border. Later in the year the United States began to arm and train the Thai army and to provide the kingdom general economic aid.43

Walker notes how the collapse of the KMT forces in China led Washington to subordinate its antinarcotics policies to the containment of communism: By the fall of 1949 . . . reports reached the State Department about the inroads communism was making within the Chinese community in Thailand as well as the involvement of the Thai army with opium. Since the army virtually controlled the nature of Thailand’s security relationship with the West, foreign promotion of opium control had to take a back seat to other policy priorities.44

On March 9, 1950, when Truman was asked to approve $10 million in military aid for Thailand, Acheson’s supporting memo noted that $5 million had already been approved by Truman for the Thai “constabulary.”45 This presumably came from the OPC’s secret budget: I can find no other reference to the $5 million in State Department published records, and two years later a U.S. aid official in Washington, Edwin Martin, wrote in a secret memo that the Thai Police force under General Phao “is receiving no American military aid.”46

Cliques, the Mob, the KMT, and Operation Paper

The U.S. decision to back the KMT troops—the so-called Li Mi project or Operation Paper—was made at a time of intense interbureaucratic conflict and even conspiratorial disagreement over official U.S. policy toward the new Chinese People’s Republic. As the historian Bruce Cumings has shown, both the KMT-financed China Lobby and many Republicans, like Donovan, as well as General MacArthur in Japan, were furious at the failure of Secretary of State Dean Acheson to continue support for Chiang Kai-shek after the founding of the People’s Republic in October 1949.47 Up until the June 1950 outbreak of war in Korea, Acheson refused to guarantee even the security of Taiwan.48

Claire Chennault with Chiang Kai-shek and Mme Chiang

The key public lobbyist for backing the KMT in Burma and Yunnan was General Claire Chennault, original owner of the airline the OPC took over. Chennault deserves to be remembered as an early postwar proponent of using off-the-books assets: his “Chennault Plan” envisaged essentially self-financing KMT armies, backed by a covert U.S. logistical airline, in support of U.S. foreign policy.49 Because by this time Chennault was serving in Washington as Chiang Kai-shek’s military representative, he was viewed by U.S. officials with increasing suspicion if not distaste.50 Yet his longtime associate, friend, and business ally Thomas (“Tommy the Cork”) Corcoran, who after 1950 was a registered foreign agent for Taiwan, managed to put Chennault in contact with senior OPC officers, including Richard Stilwell, chief of the Far East Division of the OPC.51

There were other private interests with a stake in Operation Paper. In 1972 I noted that the two principal figures inside the United States who backed Chennault, Paul Helliwell and Thomas Corcoran, were both attorneys for the OSS-related insurance companies of C. V. Starr in the Far East.52 (Starr, who had operated out of Shanghai before the war, helped OSS China establish a network both there and globally.53) The C. V. Starr companies (later the massive AIG group) allegedly had “close financial ties” with Chinese Nationalists in Taiwan,54 and in any case they would of course have had a financial interest both in restoring the KMT to power in China and in consolidating a Western presence in Southeast Asia.55 At the time of Corcoran’s lobbying, Starr’s American International Assurance Company was expanding from its Hong Kong base to Malaysia, Singapore, and Thailand. In 2006, that company was “the No. 1 life insurer in Southeast Asia.”56 And its parent AIG, before AIG’s spectacular collapse in 2008, was listed by Forbes as the eighteenth-largest public company in the world.

Corcoran was also the attorney in Washington for Chiang Kai-shek’s brother-in-law T. V. Soong, the backer of the China Lobby who some believed to be the “wealthiest man in the world.”57 It is likely that Soong and the KMT helped develop the Chennault Plan. A complementary plan for supporting the remnants of General Li Mi’s KMT armies in Burma was developed in 1949 by the army’s civilian adviser, Ting Tsuo-shou, after discussions on Taiwan with Chiang Kai-shek.58

Like Chiang Kai-shek, Chennault also had support from Henry Luce of Time-Life in America and both General MacArthur and his intelligence chief, Major General Charles Willoughby, in Japan. Their plans for maintaining and reestablishing the KMT in China were in 1949 already beginning to diverge significantly from those of Truman and his State Department.59 Former OSS Chief William Donovan, now outside the government and promoting the KMT, also promoted both Chiang Kai-shek and Chennault,60 as did Chennault’s wartime associate William Pawley, a freewheeling overseas investor who, like Helliwell, reputedly had links to mob drug traffickers.61

Donovan’s support for Chennault was part of his general advocacy of rollback against communism and his interest in guerrilla armies—a strongly held ideology that, as we shall see, led to his appointment as ambassador to Thailand in 1953. His intellectual ally in this was the former Trotskyite James Burnham, another protégé of Henry Luce by then in the OPC (and a prototype of the neoconservatives half a century later). Burnham wrote in his book (“published with great Luce fanfare in early 1950”) of “rolling back” communism and of supporting Chiang Kai-shek to, at some future point, “throw the Communists back out of China.”62

The Belated Authorization of Operation Paper

In the midst of this turmoil, OPC Chief Frank Wisner began in the summer of 1948 to refinance and eventually take over Chennault’s airline, CAT, which Chiang Kai-shek’s friend Claire Chennault had organized with postwar UN relief funds to airlift supplies to the KMT armies in China. Wisner “negotiated with Corcoran for the purchase of CAT [in which Corcoran as well as Chennault had a financial interest]. In March [1950], using a ‘cutout’ banker or middleman, the CIA paid CAT $350,000 to clear up arrearages, $400,000 for future operations, and a $1 million option on the business.”63

Richard Stilwell, Far Eastern chief of the OPC and the future overseer of Operation Paper, dickered with Corcoran over the purchase price.64 The details were finalized in March 1950, shortly before the outbreak of the Korean War in June generated for CAT Inc. a huge volume of new business.65 Alfred Cox, OPC station chief in Hong Kong and the chief executive officer (CEO) of CAT Inc., directed the supply operation to Li Mi.66

According to an unfavorable assessment by Lieutenant Colonel William Corson, a former marine intelligence officer on special assignment with the CIA, the OPC,

in late summer 1950, recruited (or rather hired) a batch of Chinese Nationalist soldiers [who] were transported by the OPC to northern Burma, where they were expected to launch guerrilla raids into China. At the time this dubious project was initiated no consideration was given to the facts that (a) Truman had declined Chiang’s offer to participate in the Korean War . . . (b) Burmese neutrality was violated by this action; and (c) the troops provided by Chiang were utterly lacking in qualifications for such a purpose.67

Shortly afterward, in October 1950, Truman appointed a new and more assertive CIA director, Walter Bedell Smith. Within a week Smith took the first steps to make the OPC and Wisner answerable for the first time, at least on paper, to the CIA.68 Smith ultimately succeeded in his vigorous campaign to bring Wisner and the OPC under his control, partly by bringing in Allen Dulles to oversee both the OPC and the CIA’s rival Office of Special Operations (OSO, the successor to the Strategic Service Unit).69 Yet in November 1950, only one month after his appointment as director, Smith tried and failed to kill Operation Paper when the proposal was belatedly submitted by the OPC (backed by the Joint Chiefs) for Truman’s approval:

The JCS [Joint Chiefs of Staff] in April 1950 issued a series of recommendations, including a programme of covert assistance to local anti-communist forces. This proposal received additional stimulus following the Korean War and especially after Communist China entered that conflict. Shortly after the People’s Republic’s (PRC’s) intervention, the Central Intelligence Agency’s (CIA’s) Office of Policy Co-ordination (OPC) proposed a programme to divert the PRC’s military from the Korean peninsula. The plan called for U.S. aid to the 93rd, followed by an invasion of Yunnan by Li’s men. Interestingly, the CIA’s director, Walter Bedell Smith, opposed the plan, considering it too risky. But President Harry S. Truman saw merit in the OPC proposal and approved it. The programme became known as Operation Paper.70

It is not clear whether, when Truman approved Operation Paper in November 1950, his secretary of state, Dean Acheson, was even aware of it. It is a matter of record that the U.S. embassies in Burma and Thailand knew nothing of the authorization until well into 1951, when they learned of it from the British and eventually from Phibun himself.71 The scholar Victor Kaufman reports that he “was unable to turn up any evidence at the Truman Library, the National Archives or in the volumes of FRUS [Foreign Relations of the United States] to determine whether in fact Acheson knew of the operation and, if so, at what point.”72

Both MacArthur and Chennault had ambitious designs for the CAT-supported KMT troops in Burma. With the outbreak of the Korean War in 1950, CAT played an important role in airlifting supplies to the U.S. troops.73 But both MacArthur and Chennault spoke publicly of trapping communist China in what Chennault called a “giant pincers”—simultaneous attacks from Korea and from Burma.74

The OPC kicked in by helping to build up a major airstrip at the chief KMT base at Mong Hsat, Burma, followed by a regular shuttle transport of American arms.75 However, Li Mi’s attempts to invade Yunnan in 1951 and 1952 (three according to McCoy, seven according to Lintner) were swiftly repelled by local militiamen with heavy casualties after advances of no more than sixty miles.76 CIA advisers accompanied the incursions, and some of them were killed.77

American journalists and historians like to attribute the CIA’s Operation Paper, in support of Li Mi and the opium-growing 93rd Division in Burma, to President Truman’s authorization in November 1950, following the outbreak of the Korean War in June 1950 and above all the Chinese crossing of the Yalu River.78 But as historian Daniel Fineman points out, Truman was merely authorizing an arms shipments program that had already begun months earlier:

Shortly after the writing of the [April 1950] JCS memorandum, the United States began supplying arms and matériel to the [KMT] troops. [The Burmese protested in August 1950 that they had discovered in northern Burma an American military officer from the Bangkok embassy in Burma without authorization.79] In the fall, the . . . Office of Policy Coordination (OPC) drafted a daring plan for them to invade Yunnan. The CIA’s director, Walter Bedell Smith, opposed the risky scheme, but Truman [in November 1950] rejected his warning. . . . In January 1951, the CIA initiated its project, code-named Operation Paper. It aimed to prepare the Kuomintang (KMT) forces in Burma for an invasion of Yunnan.80

The futility of Li Mi’s military jabs against China was obvious to Washington by 1952. Yet Federal Bureau of Narcotics (FBN) Chief Harry Anslinger continued to cover up the Li Mi-Thai drug connection for the next decade. The annual trafficking reports of the FBN recorded one seizure of distinctive Thai Government Monopoly opium in 1949 and on “several occasions” more in 1950. But after the initiation of Operation Paper in 1951, the FBN over a decade listed only one seizure of Thai drugs (from two seamen), until it began reporting Thai drug seizures again in 1962.81

Meanwhile, Anslinger, who “had established a working relationship with the CIA by the early 1950s . . . blamed the PRC [People’s Republic of China, as opposed to their enemy the KMT] for orchestrating the annual movement of some two hundred to four hundred tons of opium from Yunnan to Bangkok.”82 This protection of the world’s leading drug traffickers (who were also CIA proxies) did not cease with Anslinger, nor even when the FBN, by then thoroughly corrupted from such cover-ups, was replaced in 1968 by the Bureau of Narcotics and Dangerous Drugs and finally in 1973 by the Drug Enforcement Administration. As I write in 2010, the U.S. media are blaming the drug traffic in Afghanistan on the Taliban-led insurgency, but UN statistics (examined later in this book) suggest that insurgents receive less than 12 percent of the total drug revenues in Afghanistan’s totally drug-corrupted economy.

Harry Anslinger

As we saw in the previous chapter, Anslinger’s tenure at the FBN was when the CIA also forged anticommunist drug alliances in Europe in the 1940s with the Italian Mafia in Sicily and the Corsican Mafia in Marseilles. The KMT drug support operation was longer lived and had more lasting consequences in America as well as in Southeast Asia. It converted the Golden Triangle of Burma–Thailand–Laos, which before the war had been marginal to the global drug economy, into what was for two decades the dominant opium-growing area of the world.

Did Some People Intend to Develop the Drug Traffic with Operation Paper?

The decision to arm Li Mi was obviously controversial and known to only a few. Some of those backing the OPC’s support of a pro-KMT airline and troops may have envisaged from the outset that the 93rd Division would continue, as during the war, to act as drug traffickers. The key figure, Paul Helliwell, may have had a dual interest, inasmuch as he not only was a former OSS officer but also at some point became the legal counsel in Florida for the small Miami National Bank used after 1956 by Meyer Lansky to launder illegal funds.83 We shall see in the next chapter that Helliwell also went on to represent Phao’s drug-financed government in the United States and to receive funds from that source.84

It is possible that in the mind of Helliwell, with his still ill-understood links to the underworld and Meyer Lansky, Li Mi’s troops were not being used to invade China so much as to restore the war-dislocated international drug traffic that supported the anticommunist KMT and the comprador capitalist activities of its supporters throughout Southeast Asia.85 (As a military historian has commented, “Li Mi was more Mafia or war lord than Chinese Nationalist. Relying on his troops to bring down Mao was an OPC pipe dream.”86)

It is possible also that other networks associated with the drug traffic became part of the infrastructure of the Li Mi operation. This question can be asked of some of the ragtag group of pilots associated with Chennault’s airlines in Asia, some of whom were rumored to have seized this opportunity for drug trafficking.87 According to William R. Corson (a marine colonel assigned at one point to the CIA),

The opium grown by the ChiNat guerrillas . . . was transported by OPC contract aircraft from the forward base to Bangkok for sale to buyers from the various “connections.” The pilots who flew these bushtype aircraft and often served as agents or go-betweens with the guerrilla leaders and the opium buyers were a motley band of men. Some were ex-Nazis, others part of the band of expatriates who emerge in foreign countries following any war.88

The FBN by this time was aware that Margaret Chung, the attending physician to the pilots of Chennault’s wartime airline, was involved with Bugsy Siegel’s friend Virginia Hill “in the narcotic traffic in San Francisco.”89 During World War II, when the Office of Naval Intelligence through the OSS approached Dr. Chung for some specific intelligence on China, she “volunteered that she could supply detailed information . . . ‘from some of the smugglers in San Francisco.’”90

One has to ask what was in the mind of Chennault. Chennault himself was once investigated for smuggling activities, “but no official action was taken because he was politically untouchable.”91 I have no reason to suspect that Chennault wished to profit personally from the drug traffic. But his objective in opposing Chinese communists was to split off ethically divergent provinces like Xinjiang, Tibet, and above all Yunnan.

Chennault’s top priority was Yunnan, with its long-established Haw (or Hui) Muslim minority, many of whom (especially in southwestern Yunnan) traditionally dominated the opium trade into Thailand.92 The troops of the reconstituted 93rd Division were principally Haws from Yunnan.93 To this day, one Thai name for the KMT Yunnanese minority in northern Thailand is gaan beng gaaosipsaam (“93rd Division”), and visitors to the former base of the KMT general Duan Xiwen in Thailand (Mae Salong) are struck by the mosque one sees there.94

I suspect that Chennault may have known that none of the elements in the reconstituted 93rd Division “had made great records of military accomplishment” during World War II,95 that the 93rd had been engaged in drug trafficking when based at Jinghong during World War II,96 and that when the 93rd Division moved into northern Burma and Laos in 1946, it was “in reality, to seize the opium harvest there.”97 That the 93rd Division settled into managing the postwar drug traffic out of Burma should have come as no surprise. Chennault was close to Madame Chiang Kai-shek, T. V. Soong, and the KMT, which had been supporting itself from opium revenues since the 1930s.98 Linked to drug trafficking both in Thailand (through the Tai Li spy network) and in America, the KMT, after expulsion from Yunnan, desperately needed a new opium supply to maintain its contacts with the opiumtrafficking triads and other former assets of Tai Li in Southeast Asia.99

From the time of the inception of the KMT government in the 1920s, KMT officials had been caught smuggling opium and heroin into the United States.100 As noted earlier, an FBN supervisor reported in 1946 that “in a recent Kuomintang Convention in Mexico City a wide solicitation of funds for the future operation of the opium trade was noted.” In July 1947 the State Department reported that the Chinese Nationalist government was “selling opium in a desperate attempt to pay troops still fighting the Communists.”101 The New York Times reported on July 23, 1949, the seizure in Hong Kong of twenty-two pounds of heroin that had arrived from a CIA-supplied Kuomintang outpost in Kunming.102 But the loss of Yunnan in 1949–1950 meant that the KMT would have to develop a new source of supply.

The key to the survival of the KMT was of course its establishment and protection after 1949 on the island of Taiwan. Chennault and his airline CAT helped move the KMT leadership and its resources to its new base and to deny the new Chinese People’s Republic the Chinese civil air fleet (which became embroiled in a protracted Hong Kong legal battle where CAT was represented by William Donovan).103 By 1950 one of Chennault’s wartime pilots, Satiris (or Soteris or Sortiris) Fassoulis ran a firm, Commerce International China, Inc., that privately supplied arms and military advisers to Chiang Kai-shek on Taiwan. Bruce Cumings speculates that he may have done so for the OPC at a time when Acheson was publicly refusing to commit the United States to the defense of Taiwan.104

Finally, all those handling Operation Paper in and for the OPC (Fitzgerald, Helliwell, Joost, CAT Inc. CEO Alfred Cox, and Bird) had had experience in the area during World War II. If they had not wanted Li Mi and CAT to be- come involved in restoring the KMT drug traffic, it would have been imperative for them to ensure that the KMT on Taiwan had no control over CAT’s operations. But Wisner and Helliwell did the exact opposite: when they took over the CAT airline, they gave majority control of the CAT planes to the KMT-linked Kincheng Bank on Taiwan.105 Thereafter for many years CAT planes would fly arms into Li Mi’s camp for the CIA and then fly drugs out for the KMT.

The opium traffic may well have seemed attractive to OPC for strategic as well as financial reasons. As Alfred McCoy has observed, Phao’s pro-KMT activities in Thailand “were a part of a larger CIA effort to combat the growing popularity of the People’s Republic among the wealthy, influential overseas Chinese community throughout Southeast Asia.”106 I have noted elsewhere that the KMT reached these communities in part through triads and other secret societies (especially in Malaya) that had traditionally been involved in the opium traffic. Thus, the restoration of an opium supply in Burma to replace that being lost in Yunnan had the result of sustaining a social fabric and an economy that was capitalist and anticommunist.107

I would add today that the opium traffic was an even more important element in an anticommunist strategy for Southeast Asia as a source of income. We have already seen that for a century, the Thai state had relied on its revenues from the state opium monopoly; in 1953 “the Thai representative at the April CND [Commission on Narcotic Drugs] session had admitted that his country could not afford to give up the revenue from the opium business.”108

Just as important was the role of opium profits in promoting capitalism among the Chinese businessmen of Southeast Asia (the agenda of Sir William Stephenson and the WCC). Whether the Chinese who dominated business in the region would turn their allegiance to Beijing depended on the availability of funds for alternative business opportunities. Here Phao’s banker, Chin Sophonpanich, became a source of funds for top anticommunist businessmen not only in Thailand but also in Malaysia and Indonesia:

Chin Sophonpanich created the largest bank in south-east Asia and one that was extremely profitable. A report by the International Monetary Fund in 1973 claimed that Bangkok Bank’s privileged position allowed it to make returns on its capital in excess of 100 per cent a year (a claim denounced by Chin’s lieutenants). What was not in dispute was that the bank’s bulging deposit base could not be lent out at optimum rates in Thailand alone. This is where Chin revolutionised the south-east Asian banking scene. He personally travelled between Hong Kong, Singapore, Kuala Lumpur and Jakarta, identifying and courting the new generation of putative post colonial tycoons. . . . Chin banked the key godfathers outside Hong Kong—Robert Kuok in Malaysia, Liem Sioe Liong [Sudono Salim] in Indonesia, the Chearavanonts in Thailand—as well as other players in Singapore and Hong Kong. . . . Chin was closely linked to the Thai heroin trade through his role as personal financier to the narcotics kingpin Phao Sriyanon, and to other politicians involved in running the drug business.109

Chin thus followed the example of the Khaw family opium farmers in nineteenth-century Siam, whose commercial influence also eventually “extended across Siam’s southern borders into Malaya and the Netherlands East Indies” into legitimate industries, such as tin mines and a shipping company.110

America had another reason to accept Li Mi’s smuggling activities: as a source of badly needed Burmese tungsten. According to Jonathan Marshall, there is fragmentary evidence that OPC/CIA support for his remnant army was “also to facilitate Western control of Burma’s tungsten resources.”111

Creation of an Off-the-Books Force without Accountability

The OPC aid to Thai police greatly augmented the influence of both Phao Sriyanon, who received it, and Willis Bird, the OSS veteran through which it passed and who was already a supplier for the Thai military and police. Seeing the gap between the generals who had organized the military coup of 1947 and U.S. Ambassador Stanton, who still worked to support civilian politicians, Bird worked with Phao and the generals of the 1947 Coup Group to create in 1950 a secret “Naresuan Committee.” Bypassing the U.S. embassy altogether, the Naresuan Committee created a parallel, parastatal channel for U.S.–Thai governmental relations between OPC and Phao’s BPP:

Bird organized in 1950 a secret committee of leading military and political figures to develop an anticommunist strategy and, more importantly, lobby the United States for increased military assistance. The group, dubbed the Naresuan Committee, included police strongman Phao Sriyanon, Sarit Thanarat, Phin Choonhawan, Phao’s father-in-law, air force chief Fuen Ronnaphakat, and Bird’s [Anglo-Thai] brother-in-law, [air force colonel] Sitthi [Savetsila, later Thailand’s foreign minister for a decade]. . . . Bird and the generals established their committee to bypass the ambassador and . . . work through [Bird’s] old OSS buddies now employed by the CIA [sic, i.e., OPC].112

Thomas Lobe, ignoring Bird, writes that it was the “Thai military clique” who organized the committee. But from his own prose we learn that the initiative may have been neither theirs nor Bird’s alone but in implementation of a new strategy of support to the KMT in Burma, designed by the OPC and JCS in Washington:

A high-ranking U.S. military officer and a CIA [OPC] official came to Bangkok [in 1950] to review the political situation.113 . . . Through the “[Naresuan] Anti-Communist Committee,” secret negotiations ensued between Phao and the CIA [OPC]. The U.S. representative explained the need for a paramilitary force that could both defend Thai borders and cross over into Thailand’s neighbors— Vietnam, Laos, Burma, Cambodia, and China—for secret missions. . . . The CIA’s new police were to be special: an elite force outside the normal chain of command of both the Thai security bureaucracy and the TNPD [Thai National Police department]. Phao and Phibun agreed to this arrangement because of the increase in armed power that this new national police meant vis-à-vis the armed forces.114

This was in keeping with the JCS call in April 1950 for a new “program of special covert operations designed to interfere with Communist activities in Southeast Asia,” noting “the evidences of renewed vitality and apparent increased effectiveness of the Chinese Nationalist forces.”115

Action was taken immediately:

[Bird’s] CIA [i.e., OPC] contacts sent an observer to meet the committee and, impressed with the resolve the Thais manifested, got Washington to agree to a large covert assistance program. Because they considered the matter urgent, planners on both the Thai and American sides decided to forgo a formal agreement on the terms of the aid. Instead, Paul Helliwell, an OSS friend of Bird [from China] now practicing law in Florida [as well as military reserve officer and OPC operative], incorporated a dummy firm in Miami named the Sea (i.e. South-East Asia) Supply Company as a cover for the operation. The CIA [OPC], the agency on the American end responsible for the assistance, opened a Sea Supply office in Bangkok. . . . By the beginning of 1951, Sea Supply was receiving arms shipments for distribution. . . . The CIA [OPC] appointed Bird’s firm general agent for Sea Supply in Bangkok.116

Sea Supply’s arms from Bird soon reached not only the Thai police and BPP but also, starting in early 1951, the KMT 93rd Division in Burma, which was still supporting itself, as during the war, from the opium traffic.117 General Li Mi, the postwar commander of the 93rd Division, would consult with Bird and Phao in Bangkok about the arms that he needed for the KMT base at Mong Hsat in Burma and that had already begun to reach him months before the creation of the Bangkok Sea Supply office in January 1951.118 The airline supplying the KMT base at Mong Hsat in Burma from Bangkok was Helliwell’s other OPC proprietary, CAT Inc., which in 1959 changed its name to become the well-known Air America. The deliberately informal arrangement for Sea Supply served to mask the sensitive arms shipments to a KMT opium base.119

Air America U-10D Helio Courier aircraft in Laos on a covert mountaintop landing strip (LS) „Lima site“

In the complex legal takeover of Chennault’s airline, his assets developed into three separate components: planes (the Taiwanese civilian airline In the complex legal takeover of Chennault’s airline, his assets developed into three separate components: planes (the Taiwanese civilian airline Civil Air Transport or CATCL), pilots (later Air America), and ground-support operations (Air Asia). Of these the planes only 40 percent were owned by the CIA; the remaining 60 percent continued to be owned by KMT financiers (with alleged links to T.V. Soong and Mme. Chiang K ai-shek), who had relocated to Taiwan and were associated with the Kincheng Bank.120 The Kincheng Bank was under the control of the so-called Political Science Clique of the KMT, whose member Chen Yi was the first postwar KMT governor of Taiwan.121

The OPC’s organizational arrangements for its proprietary CAT, which left 60 percent of the company owning the CAT planes in KMT hands, guaranteed that CAT’s activities were immune to being reined in by Washington.122

In fact Helliwell, Bird, and Bird’s Thai brother-in-law Sitthi Savetsila all avoided the U.S. embassy and instead plotted strategy for the KMT armies at the Taiwanese embassy. There the real headquarters for Operation Paper was the private office of Taiwanese Defense Attaché Chen Zengshi, a graduate of China’s Whampoa Military Academy.123

Bird’s energetic promotion of Phao, precisely at a time when the U.S. embassy was trying to reduce Phao’s corrupt influence, led to a 1951 embassy memorandum of protest to Washington about Bird’s activities. “Why is this man Bird allowed to deal with the Police Chief [Phao]?” the memo asked.124 The question, for which there is no publicly recorded reply, was an urgent one. Bird’s backing of the so-called Coup Group (Phin Choonhavan, Phao Sriyanon, and Sarit Thanarat), reinforced by the obvious U.S. support for Bird through Operation Paper and Sea Supply, encouraged these military men, in their November 1951 “Silent Coup,” to defy Stanton, dissolve the Thai parliament, and replace the postwar Thai constitution with one based on the much more reactionary constitution of 1932.125

The KMT Drug Legacy for Southeast Asia

When the OPC airline CAT began its covert flights to Burma in the 1950s, the area produced about eighty tons of opium a year. In ten years’ time, production had at least quadrupled, and at one point during the Vietnam War, the output from the Golden Triangle reached 1,200 tons a year. By 1971, there were also at least seven heroin labs in the region, one of which, close to the CIA base of Ban Houei Sai in Laos, produced an estimated 3.6 tons of heroin a year.126

The end of the Vietnam War did not interrupt the flow of CIA-protected heroin to America from the KMT remnants of the former 93rd Division, now relocated in northern Thailand under Generals Li Wenhuan and Duan Xiwen (Tuan Hsi-wen). The two generals, by then officially integrated into the defense forces of Thailand, still enjoyed a special relationship to and protection from the CIA. With this protection, Li Wenhuan, from his base in Tam Ngob, became, according to James Mills, “one of the most powerful narcotics traffickers on earth . . . controlling the opium from which is refined a major percentage of heroin entering the United States.”127

From the very outset of Operation Paper, the consequences were felt in America itself. As I have shown elsewhere, most of the KMT-Thai opium and heroin was distributed in America by KMT-linked tongs with long-term ties to the American mafia.128 Thus, Anslinger’s rhetoric served to protect the primary organized crime networks distributing Asian narcotics in America. Far more than the CIA drug alliances in Europe, the CIA’s drug project in Asia contributed to the drug crisis that afflicted America during the Vietnam War and from which America still suffers. Furthermore, U.S. protection of leading KMT drug traffickers led to the neutralization of domestic drug enforcement at a high level. It has also inflicted decades of militarized oppression on the tribes of eastern Myanmar (Burma), perhaps the principal victims of this story.

By the end of 1951, Truman, convinced that the KMT forces in Burma were more of a threat to his containment policy than an asset, “had come to the conclusion that the irregulars had to be removed.”129 Direct U.S. support to Li Mi ended, forcing the KMT troops to focus even more actively on proceeds from opium, soon supplemented by profits from morphine labs as well. But nevertheless, in June 1952, as we shall see, 100 Thai graduates from the BPP training camp were in Burma training Li Mi’s troops in jungle warfare.130 After a skirmish in 1953, the Burma army recovered the corpses of three white men, with no identification except for some documents with addresses in Washington and New York.131 Operation Paper was by now leading a life of its own, independent not just of Ambassador Stanton but even of the president.

A much-publicized evacuation of troops to Taiwan in 1953–1954 was a charade, despite five months of strenuous negotiations by William Donovan, by then Eisenhower’s ambassador in Thailand. Old men, boys, and hill tribesmen were airlifted by CAT from Thailand and replaced by fresh troops, new arms, and a new commander.132

The fiasco of Operation Paper led in 1952 to the final absorption of the OPC into the CIA. According to R. Harris Smith,

Bedell Smith . . . summoned the OPC’s Far East director, Richard Stilwell, and, in the words of an agency eyewitness, gave him such a “violent tongue lashing” that “the colonel went down the hall in tears.” . . . [T]he Burma debacle was the worst in a string of OPC affronts that confirmed his decision to abolish the office. In 1952 he merged the OPC with the CIA’s Office of Special Operations [to create a new Directorate of Plans].133

What precipitated this decision was an event remembered inside the agency as the “Thailand flap.” Its precise nature remains unknown, but central to it was a drugs-related in-house murder. Allen Dulles’s biographer recounts that in 1952 Walter Bedell Smith “had to send top officials of both clandestine branches [the CIA’s OSO and OPC] out to untangle a mess of opium trading under the cover of efforts to topple the Chinese communists.”134 (I heard from a former CIA officer that an OSO officer investigating drug flows through Thailand was murdered by an OPC officer.135) Years later, at a secret Council on Foreign Affairs meeting in 1968 to review official intelligence operations, former CIA officer Richard Bissell referred back to the CIA–OPC flap as “a total disaster organizationally.”136

But what was an organizational disaster may be seen as having benefited the political objectives of the wealthy New York Republicans in OPC (including Wisner, Fitzgerald, Burnham, and others) who constituted an overworld enclave committed to rollback inside the Truman establishment committed to containment. (Recall that Wisner had surrounded himself in the OPC with men who, in the words of Wisner’s ex-wife, “had money enough of their own to be able to come down” to Washington.137) This enclave was already experimenting with attempts to launch the rollback policy that Eisenhower and John Foster Dulles would call for in the 1952 election campaign.138

Truman, understandably and rightly, mistrusted this enclave of overworld Wall Street Republicans that the CIA and OPC had injected into his administration. The four directors Truman appointed to oversee central intelligence—Sidney Souers, Hoyt Vandenberg, Roscoe Hillenkoetter, and Walter Bedell Smith—were all from the military and all (like Truman himself) from the central United States.139 This was in striking contrast to the six known deputy directors below them, whose background was that of New York City or (in one case) Boston, law and/or finance, and (in all cases but one) the Social Register.140

But Bedell Smith, Truman’s choice to control the CIA, inadvertently set the stage for overworld triumph in the agency when, in January 1951, he brought in Allen Dulles (Wall Street Republican, Social Register, and OSS) “to control Frank Wisner.”141 And with the Republican election victory of 1952, Bedell Smith’s intentions in abolishing the OPC were completely reversed. Desmond Fitzgerald of the OPC, who had been responsible for the controversial Operation Paper, became chief of the CIA’s Far East Division.142 American arms and supplies continued to reach Li Mi’s troops, no longer directly from OPC but now indirectly through either the BPP in Thailand or the KMT in Taiwan.

The CIA support for Phao began to wane in 1955–1956, especially after a staged BPP seizure of twenty tons of opium on the Thai border was exposed by a dramatic story in the Saturday Evening Post.144 But the role of the BPP in the drug trade changed little, as is indicated in a recent report from the Asian Human Rights Commission in Hong Kong. Meanwhile, for at least seven years, the BPP would “capture” KMT opium in staged raids, and turn it over to the Thai Opium Monopoly. The “reward” for doing so, one-eighth the retail value, financed the BPP.143

The police force that exists in Thailand today is for all intents and purposes the same one that was built by Pol. Gen. Phao Sriyanond in the 1950s. . . . It took on paramilitary functions through new special units, including the border police. It ran the drug trade, carried out abductions and killings with impunity, and was used as a political base for Phao and his associates. Successive attempts to reform the police, particularly from the 1970s onwards, have all met with failure despite almost universal acknowledgment that something must be done.145

The last sentence could equally be applied to America with respect to the CIA’s involvement in the global drug connection.

Peter Dale Scott, a former Canadian diplomat and English Professor at the University of California, Berkeley, is the author of Drugs Oil and War, The Road to 9/11, The War Conspiracy: JFK, 9/11, and the Deep Politics of War. His American War Machine: Deep Politics, the CIA Global Drug Connection and the Road to Afghanistan from which the present article is excerpted, has just been published.

Recommended citation: Peter Dale Scott, „Operation Paper: The United States and Drugs in Thailand and Burma,“ The Asia-Pacific Journal, 44-2-10, November 1, 2010.

Notes

1 William O. Walker III, “Drug Trafficking in Asia,” Journal of Interamerican Studies and World Affairs 34, no. 3 (1992): 204.

2 William Peers [OSS/CIA] and Dean Brellis, Behind the Burma Road (Boston: Little, Brown, 1963), 64.

3 Burton Hersh, The Old Boys: The American Elite and the Origins of the CIA (New York: Scribner’s, 1992), 300.

4 Peter Dale Scott, “Mae Salong,” in Mosaic Orpheus (Montreal: McGill-Queen’s University Press, 2009), 45.

5 Peter Dale Scott, “Wat Pa Nanachat,” in Mosaic Orpheus, 56.

6 Note Omitted.

7 I write about this practice in Drugs, Oil, and War: The United States in Afghanistan, Colombia, and Indochina (Lanham, MD: Rowman & Littlefield, 2003).

8 There are analogies also with the history of U.S. involvement in Iraq, though here the analogies are not so easily drawn. The most relevant point is that U.S. success in the defense of Kuwait during the 1990–1991 Gulf War once again produced internal pressures, dominated by the neoconservative clique and the Cheney–Rumsfeld–Project for the New American Century cabal, which ultimately pushed the United States into another rollback campaign, the current invasion of Iraq itself.

9 G. William Skinner, Chinese Society in Thailand: An Analytical History (Ithaca, NY: Cornell University Press, 1957), 166–67; Alfred W. McCoy, The Politics of Heroin: CIA Complicity in the Global Drug Trade (Chicago: Lawrence Hill Books/Chicago Review Press, 2003), 101; Bertil Lintner, Blood Brothers: The Criminal Underworld of Asia (New York: Palgrave Macmillan, 2002), 234.

10 Carl A. Trocki, “Drugs, Taxes, and Chinese Capitalism in Southeast Asia,” in Opium Regimes: China, Britain, and Japan, 1839–1952, ed. Timothy Brook and Bob Tadashi Wakabayashi (Berkeley: University of California Press, 2000), 99.

11 McCoy, The Politics of Heroin, 102; James C. Ingram, Economic Change in Thailand, 1850–1970 (Stanford, CA: Stanford University Press, 1971), 177.

12 Skinner, Chinese Society in Thailand, 166–67, 236–44, 264–65.

13 Cf. Robert Maule, “British Policy Discussions on the Opium Question in the Federated Shan States, 1937–1948,” Journal of Southeast Asian Studies 33 (June 2002): 203–24.

14 One often reads that the Northern Army invasion of the Shan states was in support of the Japanese invasion of Burma. In fact, the Japanese army (which may have had its own designs on Shan opium) refused for some months to allow the Thai army to move until the refusal was overruled for political reasons by officials in Tokyo. See E. Bruce Reynolds, Thailand and Japan’s Southern Advance: 1940–1945 (New York: St. Martin’s, 1994), 115–17.

15 McCoy, The Politics of Heroin, 105. Cf. E. Bruce Reynolds, “‘International Orphans’—The Chinese in Thailand during World War II,” Journal of Southeast Asian Studies 28 (September 1997): 365–88: “In an effort to distance himself from the Japanese, Premier Phibun initiated secret contacts with Nationalist China through the Thai army in the Shan States and developed a scheme to transfer the capital to the northern town of Petchabun with the idea of ultimately turning against the Japanese and linking up militarily with Nationalist China.” Under orders from Thai Premier Phibun, rapprochement of the Northern Army in Kengtung with the KMT began in January 1943 with a symbolic release of prisoners followed by a cease fire (“Thailand and the Second World War”).

16 E. Bruce Reynolds, Thailand’s Secret War: The Free Thai, OSS, and SOE during World War II (Cambridge: Cambridge University Press, 2005), 170–71.

17 McCoy, The Politics of Heroin, 162–63, citing Archimedes L. A. Patti, Why Vietnam (Berkeley: University of California Press, 1980), 216–17, 265, 354–55, 487. Lung Yun’s son, Lung Shing, denied to James Mills that his father was a smuggler: “My family’s been painted as the biggest drug runner. This is nonsense. The government in the old days put a tax on opium, which is true. It’s been doing that for the past hundred years. You can’t pin it on my family for that” (James Mills, The Underground Empire: Where Crime and Governments Embrace [New York: Dell, 1986], 737).

18 The directions given by Washington to the OSS mission were to establish contact with Phibun’s political enemy, Pridi Phanomyong. However, the mission’s leader, Khap Kunchon, was secretly a Phibun loyalist with a history of sensitive missions, and this complication helps to explain Khap’s motive and success in promoting the Thai–KMT talks (Nigel J. Brailey, Thailand and the Fall of Singapore: A Frustrated Asian Revolution [Boulder, CO: Westview Press, 1986], 100).

19 Judith A. Stowe, Siam Becomes Thailand: A Story of Intrigue (Honolulu: University of Hawai‘i Press, 1991), 282. The border itself, a product of Sino–British negotiations in the nineteenth century, was an artifact, dividing the historically connected principalities of the Thai Lü in Sipsongpanna (southern Yunnan) from those of the Thai Yai (Shans) in Burma (Stephen Sparkes and Signe Howell, The House in Southeast Asia: A Changing Social, Economic and Political Domain [London: RoutledgeCurzon, 2003], 134; Janet C. Sturgeon, Border Landscapes: The Politics of Akha Land Use in China and Thailand [Seattle: University of Washington Press, 2005], 82).

20 Stowe, Siam Becomes Thailand, 282–83. I have discovered no indication as to whether Nicol Smith, the American leader of the OSS mission, was aware of the implications of the talks for the future of the Shan opium trade.

21 Reynolds, Thailand’s Secret War, 171, 175–76.

22 Reynolds, Thailand’s Secret War, 171; Brailey, Thailand and the Fall of Singapore, 100; Maochun Yu, OSS in China: Prelude to Cold War (New Haven, CT: Yale University Press, 1996), 117; John B. Haseman, The Thai Resistance Movement (Chiang Mai: Silkworm Books, 2002), 62–63; Stowe, Siam Becomes Thailand, 282; Nicol Smith and Blake Clark, Into Siam: Underground Kingdom (Indianapolis: Bobbs-Merrill, 1946), 146. According to Smith, General Lu himself took responsibility for delivering a message from OSS promising amnesty to the Northern Army; according to Haseman, the letter “was delivered to front-line Thai positions, who passed it in turn to Sawaeng [Thappasut, a former student of Khap’s], MG Han [Songkhram], LTG Chira [Wichitsongkhram], and to Marshal Phibul.”

23 Miles, Donovan’s first OSS chief for China, became more and more closely allied with the controversial Tai Li in a semiautonomous network, SACO. In December 1943 Donovan, alerted to the situation, replaced Miles as OSS China chief with Colonel John Coughlin (Richard Harris Smith, OSS: The Secret History of America’s First Central Intelligence Agency [Berkeley: University of California Press, 1972], 246–58).

24 Reynolds, Thailand’s Secret War, 191–92, citing documents of September 1944, cf. 175; Stowe, Siam Becomes Thailand, 270.

25 Cf. Jonathan Marshall, “Opium, Tungsten, and the Search for National Secu- rity, 1940–52,” in Drug Control Policy: Essays in Historical and Comparative Perspective, ed. William O. Walker III (University Park: Pennsylvania State University Press, 1992), 96: “Americans . . . knew that [Tai Li’s] agents protected Tu’s huge opium convoys”; Douglas Valentine, The Strength of the Wolf: The Secret History of America’s War on Drugs (London: Verso, 2004), 47: “It was an open secret that Tai Li’s agents escorted opium caravans from Yunnan to Saigon and used Red Cross operations as a front for selling opium to the Japanese.”

26 After the final KMT defeat of 1949, the 93rd Division received other remnants from the KMT 8th and 26th Armies and a new commander, General Li Mi of the KMT Eighth Army (Bertil Lintner, Burma in Revolt: Opium and Insurgency since 1948 [Chiang Mai: Silkworm Books, 1999], 111–15).

27 McCoy, The Politics of Heroin, 106, 188–91, 415–20.

28 Thomas Lobe, United States National Security Policy and Aid to the Thailand Police (Denver: Graduate School of International Studies, University of Denver, 1977), 27.

29 Lintner, Burma in Revolt, 192.

30 Lintner, Blood Brothers, 241–44. After Sarit died in 1963, Chin was able to return to Thailand.

31 William Stevenson, The Revolutionary King: The True-Life Sequel to The King and I (London: Constable and Robinson, 2001), 4, 162, 195. The king personally translated Stevenson’s biography of Sir William Stephenson into Thai.

32 Anthony Cave Brown, The Last Hero: Wild Bill Donovan (New York: Times Books, 1982), 797; Stevenson, The Revolutionary King, 162. In 1970, Thompson’s biographer, William Warren, described the funding of Thompson’s company in some detail but made no reference to the WCC (William Warren, Jim Thompson: The Unsolved Mystery [Singapore: Archipelago Press, 1998], 66–67). Former CIA officer Richard Harris Smith wrote that Thompson was later “frequently reported to have CIA connections” (Smith, OSS, 313n). Joe Trento, without citing any sources, places Jim Thompson at the center of this chapter’s narrative: “Jim Thompson . . . (who in fact was a CIA officer) had recruited General Phao, head of the Thai police, to accept the KMT army’s drugs for distribution” (Joseph J. Trento, The Secret History of the CIA [New York: Random House/Forum, 2001], 346). Thompson disappeared mysteriously in Malaysia in 1967; his sister, who investigated the disappearance, was brutally murdered in America a few months later.

33 Valentine, The Strength of the Wolf, 155. Helliwell in Kunming used opium, which was in effect the local hard currency, to purchase intelligence (Wall Street Journal, April 18, 1980).

34 Sterling Seagrave, The Marcos Dynasty (New York: Harper and Row, 1988), 361.

35 John Loftus and Mark Aarons, The Secret War against the Jews (New York: St. Martin’s, 1994), 110–11.

36 The best evidence of this, the M-fund reported on by Chalmers Johnson, is discussed in the next chapter. Cf. Sterling and Peggy Seagrave, Gold Warriors: America’s Secret Recovery of Yamashita’s Gold (London: Verso, 2003), 3. The Seagraves link Helliwell to the movement of Japanese gold out of the Philippines, and they suggest, by hearsay but without evidence, that both Sea Supply Inc. and Civil Air Transport were thus funded (147–48, 152). Although many of their startling allegations are beyond my competence to assess or even believe, there are at least two that I have verified from my own research. I am persuaded that in the first postwar months when the United States was already supporting and using the SS war criminal Klaus Barbie, the operation was paid by SS funds. And I have seen secret documentary proof that a large sum of gold was indeed later deposited in a Swiss bank account in the name of a famous Southeast Asian leader, as claimed by the Seagraves.

37 Leonard Slater, The Pledge (New York: Pocket Books, 1971), 175. An attorney once made the statement that Burton Kanter (Helliwell’s partner in the money-laundering Castle Bank) “was introduced to Helliwell by General William J. Donovan. . . . Kanter denied that. ‘I personally never met Donovan. I believe I may have spoken to him once at Paul Helliwell’s request’” (Pete Brewton, The Mafia, CIA and George Bush [New York: S.P.I. Books, 1992], 296).

38 In the course of Operation Safehaven, the U.S. Third Army took an SS major “on several trips to Italy and Austria, and, as a result of these preliminary trips, over $500,000 in gold, as well as jewels, were recovered” (Anthony Cave Brown, The Secret War Report of the OSS [New York: Berkeley, 1976], 565–66).

39 Amy B. Zegart, Flawed by Design: The Evolution of the CIA, JCS, and NSC (Stanford, CA: Stanford University Press, 1999), 189, citing Christopher Andrew, For the President’s Eyes Only (New York: HarperCollins, 1995), 172; see also U.S. Congress, Senate, 94th Cong., 2nd sess., Select Committee to Study Governmental Operations with Respect to Intelligence Activities, Final Report, April 26, 1976, Senate Report No. 94-755, 28–29.

40 Stevenson, The Revolutionary King, 50. Douglas Valentine claims that in mid-1947, Donovan intervened in Bangkok politics to resolve a conflict between the police and the army over the opium traffic. In 1947, Donovan was a registered foreign agent for the civilian Thai government, representing them in negotiations over the post-war border with French Indochina. Valentine reports that in mid-1947, “Donovan traveled to Bangkok to unite the squabbling factions in a strategic alliance against the Communists” and that the KMT businessmen in Bangkok who managed the flow of narcotics from Thailand to Hong Kong and Macao “benefited greatly from Donovan’s intervention” (Valentine, The Strength of the Wolf, 70). He notes also that “by mid-1947 Kuomintang narcotics were reaching America through Mexico.” What actually happened in November 1947 in Thailand was the ousting of Pridi’s civilian government in a military coup. Soon afterward the first of Thailand’s postwar military dictators, Phibun, took office. Not long after Phibun’s accession, Thailand quietly abandoned the antiopium campaign announced in 1948, whereby all opium smoking would have ended by 1953 (Francis W. Belanger, Drugs, the U.S., and Khun Sa [Bangkok: Editions Duang Kamol, 1989], 75–90).

41 Stevenson, The Revolutionary King, 50–51.

42 William O. Walker III, Opium and Foreign Policy: The Anglo-American Search for Order in Asia, 1912–1954 (Chapel Hill: University of North Carolina Press, 1991), 184–85, citing letters from Bird, April 5, 1948, and Donovan, April 14, 1948 (Donovan Papers, box 73a, Military History Institute, U.S. Army, Carlisle Barracks, Pennsylvania).

43 Paul M. Handley, The King Never Smiles: A Biography of Thailand’s Bhumipol Adulyadej (New Haven, CT: Yale University Press, 2006), 105.

44 Walker, Opium and Foreign Policy, 185.

45 Foreign Relations of the United States, 1949–1951 (hereinafter FRUS) (Washington, DC: Government Printing Office), vol. 6, 40–41; memo of March 9, 1950, from Dean Acheson, secretary of state.

46 FRUS, 1952–1954, vol. 12, 651, memo of October 7, 1952, from Edwin M. Martin, special assistant to the secretary for mutual security affairs, to John H. Ohly, assistant director for program, Office of the Director of Mutual Security (emphasis added).

47 Shortly before his dismissal on April 11, 1951, MacArthur in Tokyo issued a statement calling for a “decision by the United Nations to depart from its tolerant effort to contain the war to the area of Korea, through an expansion of our military operations to its coastal areas and interior bases [to] doom Red China to risk the imminent military collapse” (Lintner, Blood Brothers, 237).

48 Bruce Cumings, The Origins of the Korean War, vol. 2 (Princeton, NJ: Princeton University Press, 1990). Donovan in this period became vice chairman of the Committee to Defend America by Aiding Anti-Communist China.

49 Martha Byrd, Chennault: Giving Wings to the Tiger (Tuscaloosa: University of Alabama Press, 1987), 325–28; William M. Leary, Perilous Missions: Civil Air Transport and CIA Covert Operations in Asia, 1946–1955 (Tuscaloosa: University of Alabama Press, 1984), 67–68; Scott, Drugs, Oil, and War, 2.

50 Jack Samson, Chennault, 62.

51 John Prados, Safe for Democracy: The Secret Wars of the CIA (Chicago: Ivan R. Dee, 2006), 125. Cf. Los Angeles Times, September 22, 2000: “Newly declassified U.S. intelligence files tell the remarkable story of the ultra-secret Insurance Intelligence Unit, a component of the Office of Strategic Services, a forerunner of the CIA, and its elite counterintelligence branch X-2. Though rarely numbering more than a half dozen agents, the unit gathered intelligence on the enemy’s insurance industry, Nazi insurance titans and suspected collaborators in the insurance business. . . . The men behind the insurance unit were OSS head William “Wild Bill” Donovan and California-born insurance magnate Cornelius V. Starr. Starr had started out selling insurance to Chinese in Shanghai in 1919. . . . Starr sent insurance agents into Asia and Europe even before the bombs stopped falling and built what eventually became AIG, which today has its world headquarters in the same downtown New York building where the tiny OSS unit toiled in the deepest secrecy.”

52 Peter Dale Scott, The War Conspiracy: JFK, 9/11, and the Deep Politics of War (Ipswich, MA: Mary Ferrell Foundation Press, 2008), 46–47, 263–64. William Youngman, Corcoran’s law partner and a key member of Chennault’s support team in Washington during and after the war, was by 1960 president of a C. V. Starr company in Saigon.

53 Smith, OSS, 267.

54 Smith, OSS, 267n.

55 It is possible that other backers of the Chennault Plan allied themselves, like Helliwell, with organized crime. In those early postwar years, one of the C. V. Starr companies, U.S. Life, was the recipient of dubious Teamster insurance contracts through the intervention of the mob-linked business agents Paul and Allan Dorfman (Scott, Drugs, Oil, and War, 197; Scott, The War Conspiracy, 279). One of the principal supporters of Chennault’s airline on the U.S. West Coast, Dr. Margaret Chung, was suspected of drug trafficking after her frequent trips to Mexico City with Virginia Hill, a courier for Meyer Lansky and Bugsy Siegel. See Ed Reid, The Mistress and the Mafia: The Virginia Hill Story (New York: Bantam, 1972), 42, 90; Peter Dale Scott, “Opium and Empire: McCoy on Heroin in Southeast Asia,” Bulletin of Concerned Asian Scholars, September 1973, 49–56.

56 Ronald Shelp with Al Ehrbar, Fallen Giant: The Amazing Story of Hank Greenberg and the History of AIG (Hoboken, NJ: Wiley, 2006), 60.

57 Encyclopaedia Britannica. The money splashed around in Washington by the “China Lobby” was attributed at the time chiefly to the wealthy linen and lace merchant Joseph Kohlberg, the so-called China Lobby man. But it has often been suspected that he was fronting for others.

58 Lintner, Burma in Revolt, 111–14. As early as 1950, Ting was also actively promoting the concept of an Anti-Communist League to support KMT resistance (134, 234). The KMT’s ensuing Asian Peoples’ Anti-Communist League (later known as the World Anti-Communist League) became intimately involved with support for the KMT troops in Burma. In 1971 the chief Laotian delegate to the World Anti-Communist League, Prince Sopsaisana, was detained with sixty kilos of top-grade heroin in his luggage (Scott, Drugs, Oil, and War, 163, 194–95).

59 MacArthur advised the State Department in 1949 that the United States should place “500 fighter planes in the hands of some ‘war horse’ similar to Chennault” and further support the KMT with U.S. volunteers (memo of conversation, September 5, 1949, FRUS, 1949, vol. 9, 544–46; Cumings, The Origins of the Korean War, 103; Byrd, Chennault, 344). Chennault in turn told Senator Knowland that Congress should ap- point MacArthur a supreme commander for the entire Far East.

60 Donovan suggested that Chennault become minister of defense in a reconstituted KMT government. At some point Chennault and Donovan met privately with Willoughby in Japan (Cumings, The Origins of the Korean War, 513).

61 Valentine, The Strength of the Wolf, 260; Cumings, The Origins of the Korean War, 133.

62 Cumings, The Origins of the Korean War, 119–21, 796; James Burnham, The Coming Defeat of Communism (New York: John Day, 1951), 256–66.

63 David McKean, Peddling Influence: Thomas “Tommy the Cork” Corcoran and the Birth of Modern Lobbying (Hanover, NH: Steerforth, 2004), 216.

64 Hersh, The Old Boys, 299.

65 McKean, Peddling Influence, 216; Christopher Robbins, Air America (New York: Putnam’s, 1979), 48–49, 56–57, 70; Byrd, Chennault, 333; Alan A. Block, Masters of Paradise: Organized Crime and the Internal Revenue Service in the Bahamas (New Brunswick, NJ: Transaction, 1991), 169.

66 Curtis Peebles, Twilight Warriors: Covert Air Operations against the USSR (Annapolis, MD: Naval Institute Press, 2005), 88–89.

67 William R. Corson, The Armies of Ignorance: The Rise of the American Intelligence Empire (New York: Dial Press/James Wade, 1977), 320–21.

68 Hersh, The Old Boys, 284. Cf. Samuel Halpern (a former CIA officer) in Ralph S. Weber, Spymasters: Ten CIA Officers in Their Own Words (Wilmington, DE: Scholarly Resources, 1999), 117: “Bedell suddenly said, ‘They’re under my command.’ . . . He did it, and he did it in the first seven days of his tenure as DCI [director of the CIA].”

69 Corson, The Armies of Ignorance, 319; Daniel Fineman, A Special Relationship: The United States and Military Government in Thailand, 1947–1958 (Honolulu: University of Hawai‘i Press, 1997), 137; Henry G. Gole, General William E. DePuy: Preparing the Army for Modern War (Lexington: University Press of Kentucky, 2008), 80: “CIA Director Walter Bedell Smith opposed the plan, but President Truman approved it, overruled the Director, and ordered the strictest secrecy about it.”

70 Victor S. Kaufman, “Trouble in the Golden Triangle: The United States, Taiwan and the 93rd Nationalist Division,” China Quarterly, no. 166 (June 2001): 441, citing Memorandum, Bradley to Secretary of Defense, April 10, 1950, and Annex to NSC 48/3, “United States Objectives, Policies, and Courses of Action in Asia,” May 2, 1951. President’s Secretary’s File, National Security File—Meetings, box 212, Harry S. Truman Library, Independence, Missouri. Cf. Sam Halpern, in Weber, Spymasters, 119: “The Pentagon came up with this bright plan, as I understand it; at least, I was told this by my [CIA/OSO] boss, Lloyd George, who was Chief of the Far East Division at the time.”

71 Kaufman, “Trouble in the Golden Triangle,” 442–43; Fineman, A Special Relationship, 141–42.

72 Kaufman, “Trouble in the Golden Triangle,” 443: “Whether . . . Secretary of State Dean Acheson . . . knew of Operation Paper is uncertain. Acheson was present at discussions regarding the use of covert operations against China. . . . Yet since mid-1950, the secretary of state had been working to remove the irregulars. Therefore, either Acheson knew of the operation and did not inform his subordinates, or he too did not have the entire picture.” In apparent contradiction, William Walker writes that “Acheson had participated from the start in the decision-making process relating to NSC 48/5, so he was familiar with the discussions about using covert operations against China’s southern flank” (Opium and Foreign Policy, 203). But NSC 48/5, primarily a policy paper on Korea, dates from May 17, 1951, half a year later.

73 Leary, Perilous Missions, 116–17.

74 Lintner, Blood Brothers, 237, citing MacArthur on March 21, 1951, in Robert H. Taylor, Foreign and Domestic Consequences of the Kuomintang Intervention in Burma (Ithaca, NY: Cornell University Southeast Asia Program, Data Paper no. 93, 1973), 42; Chennault on April 23, 1958, in U.S. Congress, House Committee on Un-American Activities, International Communism (Communist Encroachment in the Far East), “Consultations with Maj.-Gen. Claire Lee Chennault, United States Army,” 85th Cong., 2nd sess., 9–10.

75 Leary, Perilous Missions, 129–30. Leary states that U.S. personnel delivered the arms only as far as northern Thailand, with the last leg of delivery handled by the Thai Border Police. But there are numerous contemporary reports of U.S. personnel at Mong Hsat in Burma who helped unload the planes and reload them with opium (Scott, Drugs, Oil, and War, 60; Corson, The Armies of Ignorance, 320–22). Lintner reproduces a photograph of three American civilians who were killed in action with the KMT in Burma in 1953 (Lintner, Burma in Revolt, 168). On April 1, 1953, the Rangoon Nation reported a captured letter from Major General Li’s headquarters, discussing “European instructors for the training of students.”

76 McCoy, The Politics of Heroin, 169–71; Lintner, Blood Brothers, 238. Despite this military fiasco, the KMT troops contributed to the survival of noncommunist Chinese communities in Southeast Asia both by serving as a protective shield and by sustaining the traditional social fabric of drug-financed KMT Triads in Southeast Asia. See McCoy, The Politics of Heroin, 185–86; Scott, Drugs, Oil, and War, 60, 192–93.

77 Donald F. Cooper, Thailand: Dictatorship of Democracy? (Montreux: Minerva Press, 1995), 120.

78 E.g., McCoy, The Politics of Heroin, 165–69. Cf. Tim Weiner, Legacy of Ashes: The History of the CIA (New York: Doubleday, 2007), 60: “The final theater for the CIA in the Korean War lay in Burma. In early 1951, as the Chinese Communists chased General MacArthur’s troops south, the Pentagon thought the Chinese Nationalists could take some pressure off MacArthur by opening a second front. . . . The CIA began [sic] flying Chinese Nationalist soldiers into Thailand . . . and dropping them along with pallets of guns and ammunition into northern Burma.” Cf. Walker, Opium and Foreign Policy, 200: “Some aid was already reaching KMT forces in Burma . . . months before the January 1951 NSC meeting.”

79 Fineman, A Special Relationship, 289n25.

80 Fineman, A Special Relationship, 137.

81 U.S. Treasury Department, Bureau of Narcotics, Traffic in Opium and Other Dangerous Drugs (Washington, DC: Government Printing Office, 1949), 13; (1950), 3; (1954), 12. Through the same decade, the FBN, by direction of the U.S. State Department, acknowledged to UN Narcotics Conferences that Thailand was a source for opium and heroin reaching the United States (Scott, Drugs, Oil, and War, 191, 203, citing UN Documents E/CN.7/213, E/CN.7/283, 22, and E/CN.7//303/Rev.1, 34; cf. Walker, Opium and Foreign Policy, 201 [State Department]). When the FBN Traffic in Opium reports began to acknowledge Thai drug seizures again in 1962, the Kennedy administration had already initiated serious efforts to remove the bulk of the KMT troops from the region (Kaufman, “Trouble in the Golden Triangle,” 452).

82 Walker, Opium and Foreign Policy, 206, cf. 213–15. Cf. also Valentine, The Strength of the Wolf, 133, 150–52. Anslinger was not alone in blaming heroin flows on mainland China. He was joined in the attack by two others with CIA connections: Edward Hunter (a veteran of OSS China and OPC who in turn was fed information regularly by Chennault) and Richard L. G. Deverall of the American Federation of Labor’s Free Trade Union Committee (under the CIA’s labor asset Jay Lovestone).

83 Scott, Drugs, Oil, and War, 7, 60–61, 198, 207, citing Penny Lernoux, In Banks We Trust (Garden City, NY: Anchor/Doubleday, 1984), 42–44, 84.

84 Fineman, A Special Relationship, 215.

85 I explore this question in Scott, Drugs, Oil, and War, 60–64.

86 Gole, General William E. DePuy, 80.

87 Chennault himself was investigated for such smuggling activities, “but no official action was taken because he was politically untouchable” (Marshall, “Opium, Tungsten, and the Search for National Security, 1940–52,” 92); cf. Barbara Tuchman, Stilwell and the American Experience in China, 1911–1945, 7–78; Paul Frillmann and Graham Peck, China: The Remembered Life (Boston: Houghton Mifflin, 1968), 152.

88 Corson, The Armies of Ignorance, 322.

89 Valentine, The Strength of the Wolf, 71, quoting Reid, The Mistress and the Mafia, 42.

90 Marshall, “Opium, Tungsten, and the Search for National Security, 1940–52,” 98, citing OSS CID 126155, April 19, 1945.

91 Marshall, “Opium, Tungsten, and the Search for National Security, 1940–52.”

92 Andrew Forbes and David Henley, The Haw: Traders of the Golden Triangle (Bangkok: Teak House, 1997).

93 Cooper, Thailand, 116.

94 Wen-chin Chang, “Identification of Leadership among the KMT Yunnanese Chinese in Northern Thailand, Journal of Southeast Asian Studies 33 (2002): 125. Chang calls this name “a popular misnomer” on the grounds that the KMT villages have been expanding and “slowly casting off their former military legacy.”

95 Taylor, Foreign and Domestic Consequences of the Kuomintang Intervention in Burma, 10.

96 McCoy, The Politics of Heroin, 162–63.

97 Sucheng Chan, Hmong Means Free: Life in Laos and America (Philadelphia: Temple University Press, 1994), 1942; cf. John T. McAlister, Viet Nam: The Origins of Revolution (Garden City, NY: Doubleday, 1971), 228; Scott, The War Conspiracy, 267.

98 Timothy Brook and Bob Tadashi Wakabayashi, eds., Opium Regimes: China, Britain, and Japan, 1839–1952 (Berkeley: University of California Press, 2000), 261–79; Jonathan Marshall, “Opium and the Politics of Gangsterism in Nationalist China, 1927–1945,” Bulletin of Concerned Asian Scholars, July–September 1976, 19–48; Laura Tyson Li, Madame Chiang Kai-shek: China’s Eternal First Lady (New York: Atlantic Monthly Press, 2006), 107, citing Nelson T. Johnson to Stanley K. Hornbeck, May 31, 1934, box 23, Johnson Papers, Library of Congress.

99 In global surveys of the opium traffic, one regularly reads of the importance of Teochew (Chiu chau) triads in the postwar Thai drug milieu (e.g., Martin Booth, Dragon Syndicates: The Global Phenomenon of the Triads [New York: Carroll and Graf, 1999], 176–77; McCoy, The Politics of Heroin, 389, 396). Although triads are central to trafficking in Hong Kong, and today possibly inside China, I question whether the Teochew in Thailand, although they certainly are prominent in the drug trade there, are still as dominated by triads as they were before World War II. Cf. Skinner, Chinese Society in Thailand, 264–67.

100 Valentine, The Strength of the Wolf, 14, citing Melvin L. Hanks, NARC: The Adventures of a Federal Agent (New York: Hastings House, 1973), 37, 162–66; Brook and Wakabayashi, Opium Regimes, 263. For an overview of U.S. knowledge of KMT drug trafficking, see Marshall, “Opium and the Politics of Gangsterism in Nationalist China, 1927–1945.”

101 Valentine, The Strength of the Wolf, 72–73, citing Terry A. Talent report of November 15, 1946; Douglas Clark Kinder and William O. Walker III, “Stable Force in a Storm: Harry J. Anslinger and United States Narcotics Policy, 1930–1962,” Journal of American History, March 1986, 919.

102 Valentine, The Strength of the Wolf, 77.

103 Victor S. Kaufman, Confronting Communism: U.S. and British Policies toward China (Columbia: University of Missouri Press, 2001), 20–21.

104 Cumings, The Origins of the Korean War, 508–25; Robert Accinelli, Crisis and Commitment: United States Policy toward Taiwan, 1950–1955 (Chapel Hill: University of North Carolina Press, 1996), 271–72; Ross Y. Koen, The China Lobby in American Politics (New York: Harper and Row, 1974), 46, 48–51. Elsewhere I have described Commerce International China as a subsidiary of the WCC. Since then, I have learned that it was a firm founded in Shanghai in 1930. I now doubt the alleged WCC connection. Later, Fassoulis was indicted in a huge organized crime conspiracy to defraud banks in a stock swindle (New York Times, September 12, 1969; Peter Dale Scott, Deep Politics and the Death of JFK [Berkeley: University of California Press, 1998], 168–69, 178). By 2005, Fassoulis was worth $150 million as chairman and CEO of CIC International, the successor to Commerce International China; his company, now supplying the U.S. armed services, was predicted to do $870 million of business (“The 50 Wealthiest Greeks in America,” National Herald, March 29, 2008). There have been speculations that the “U.S. Central Intelligence Agency . . . may actually support CIC International, Ltd. so it remains in business as one of its many brokers for arms, technology components, logistics on transactions significant to intelligence operations” (Paul Collin, “Global Economic Brinkmanship”).

105 Scott, Drugs, Oil, and War, 188.

106 McCoy, The Politics of Heroin, 185.

107 Scott, Drugs, Oil, and War, 192–93. Anslinger’s protection of the KMT traffic had the additional consequence of strengthening and protecting pro-KMT tongs in America. In 1959, when a pro-KMT Hip Sing tong network distributing drugs was broken up in San Francisco, a leading FBN official with OSS–CIA connections, George White, blamed the drug shipment on communist China while allowing the ringleader to escape to Taiwan (Scott, Drugs, Oil, and War, 63; Valentine, The Strength of the Wolf, 195).

108 Walker, Opium and Foreign Policy, 214.

109 Joe Studwell, Asian Godfathers: Money and Power in Hong Kong and Southeast Asia (New York: Atlantic Monthly Press, 2007), 95–96.

110 J. W. Cushman, “The Khaw Group: Chinese Business in Early Twentieth- Century Penang,” Journal of Southeast Asian Studies 17 (1986): 58; cf. Trocki, “Drugs, Taxes, and Chinese Capitalism in Southeast Asia,” 99–100.

111 Marshall, “Opium, Tungsten, and the Search for National Security, 1940–52,” 106. The KMT obtained the tungsten from Karen rebels controlling a major mine at Mawchj in exchange for modern arms provided by the CIA.

112 Fineman, A Special Relationship, 133, 153. Bird at the time was a “private aviation contractor” (McCoy, The Politics of Heroin, 168), and aviation was the key to the BPP strategy of defending the Thai frontier because the Thai road system was still primitive in the border areas. Because Bird included in this committee his brother-in-law, Air Force Colonel Sitthi Savetsila, Sitthi became one of Phao’s closest aides-de-camp and his translator. In the 1980s he served for a decade as foreign minister in the last Thai military government.

113 I have not been able to establish the identity of this OPC officer. One possibility is Desmond Fitzgerald, who became the overseer and champion of Sea Supply, Operation Paper, the BPP, and (still to be discussed) PARU. Another possibility is Paul Helliwell.

114 Lobe, United States National Security Policy and Aid to the Thailand Police, 19–20.

115 Fineman, A Special Relationship, 137; McCoy, The Politics of Heroin, 165.

116 Fineman, A Special Relationship, 134, emphasis added.

117 McCoy, The Politics of Heroin, 168–69: Sherman Joost, the OPC officer who headed Sea Supply in Bangkok, “had led Kachin guerrillas in Burma during the war as a commander of OSS Detachment 101.”

118 Walker, Opium and Foreign Policy, 200, 205.

119 McCoy, The Politics of Heroin, 168.

120 Scott, Drugs, Oil, and War, 187–89, 201–2; Robbins, Air America, 48–49, 56–57, 70; Leary, Perilous Missions, 110–12.

121 Chen Han-Seng, “Monopoly and Civil War in China,” Institute of Pacific Relations, Far Eastern Survey 15, no. 20 (October 9, 1946): 308.

122 Scott, Drugs, Oil, and War, 187–89. CAT was not the only airline supplying Li Mi. There was also Trans-Asiatic Airlines, described as “a CIA outfit operating along the Burma-China border against the People’s Republic of China” and based in Manila (Roland G. Simbulan, “The CIA in Manila,” Nathan Hale Institute for Intelligence and Military Affairs, August 18, 2000). On April 10, 1948, an operating agreement was signed in Thailand between the new Thai government of Phibun and Trans-Asiatic Airlines (Siam) Limited (Far Eastern Economic Review 35 [1962]: 329). Note that this was two months before NSC 10/2 formally directed the CIA to conduct “covert” rather than merely “psychological” operations and five months before the creation of the OPC in September 1948.

123 Lintner, Burma in Revolt, 146.

124 FRUS, 1951, , vol. 6, pt. 2, 1634; Fineman, A Special Relationship, 150–51. The memo described Bird as “the character who handed over a lot of military equipment to the Police, without any authorization as far as I can determine, and whose status with CAS [local CIA] is ambiguous, to say the least.”

125 Fineman, A Special Relationship, 133, 153. Handley’s otherwise well-informed account wholly ignores Bird’s role in preparing for the coup (The King Never Smiles, 113–15).

126 Scott, Drugs, Oil, and War, 40, citing McCoy, The Politics of Heroin, 162, 286–87. McCoy’s estimate of the KMT’s impact on expanding production is ex- tremely conservative. According to Bertil Lintner, the foremost authority on the Shan states of Burma, “The annual production increased from a mere 30 tons at the time of independence [1945] to 600 tons in the mid-1950s” (Bertil Lintner, “Heroin and Highland Insurgency,” in War on Drugs: Studies in the Failure of U.S. Narcotics Policy, ed. Alfred W. McCoy and Alan A. Block [Boulder, CO: Westview Press, 1992], 288). Furthermore, the KMT exploitation of the Shan states led thousands of hill tribesmen to flee to northern Thailand, where opium production also increased.

127 Mills, Underground Empire, 789. Mills also quotes General Tuan as saying that the Thai Border Police “were totally corrupt and responsible for transportation of narcotics.” Mills comments, “This was of some interest, since the BPP, a CIA creation, was known to be controlled by SRF, the Bangkok CIA station” (Mills, Underground Empire, 780). For details on the CIA–BPP relationship in the 1980s, see Valentine’s account (from Drug Enforcement Administration sources), The Strength of the Pack, 254–55.

128 Scott, Drugs, Oil, and War, 62–63, 193.

129 Kaufman, “Trouble in the Golden Triangle,” 443.

130 Fineman, A Special Relationship, 141.

131 Rangoon Nation, March 30, 1953; Cooper, Thailand, 123; McCoy, The Politics of Heroin, 174; Lintner, Burma in Revolt, 139.

132 McCoy, The Politics of Heroin, 174–76; Leary, Perilous Missions, 195–96; Lintner, Blood Brothers, 238; Life, December 7, 1953, 61.

133 McCoy, The Politics of Heroin, 177–78.

134 Peter Grose, Gentleman Spy: The Life of Allen Dulles (Boston: Richard Todd/ Houghton Mifflin, 1994), 324.

135 According to McCoy (The Politics of Heroin, 178), a CAT pilot named Jack Killam “was murdered in 1951 after an opium deal went wrong and was buried in an unmarked grave by CIA [i.e., OPC] agent Sherman Joost”—the head of Sea Supply. Joseph Trento, citing CIA officer Robert Crowley, gives the almost certainly bowd-lerized version that two “drunk and violent” CAT pilots “shot it out in Bangkok” (Trento, The Secret History of the CIA, 347). According to William Corson, “Several theories have been advanced by those familiar with the Killam case to suggest that the trafficking in drugs in Southeast Asia was used by the CIA as a self-financing device to pay for services and persons whose hire would not have been approved in Washington . . . or that it amounted to the actions of ‘rogue’ intelligence agents” (Corson, The Armies of Ignorance, 323). One consequence of these intrigues was that, as we have seen, OPC was abolished. At this time OPC Far East Director Richard Stilwell was rebuked severely by CIA Director Bedell Smith and transferred to the military. In the Pentagon, “by the end of 1981, Stilwell was running one of the most secret operations of the government” in conjunction with ex-CIA officer Theodore Shackley, a protégé of Stilwell’s former OPC deputy, Desmond Fitzgerald (Joseph J. Trento, Prelude to Terror: The Rogue CIA and the Legacy of America’s Private Intelligence Network [New York: Carroll and Graf, 2005], 213). Stilwell was advising on the creation of the U.S. Joint Special Operations Command.

136 Marchetti and Marks, CIA and the Cult, 383.

137 Hersh, The Old Boys, 301, quoting Polly (Mrs. Clayton) Fritchey. Other men prominent in the cabal responsible for Operation Paper were also Republican activists. One was Paul Helliwell, who became very prominent in Florida Republican Party politics, thanks in part to funds he received from Thailand as the Thai consul general in Miami. Harry Anslinger was a staunch Republican and owed his appointment as the first director of the FBN to his marriage to a niece of the Republican Party magnate (and Treasury Secretary) Andrew Mellon (Valentine, The Strength of the Wolf, 16). Donovan, married to a New York heiress and an OPC consultant in the late Truman years, had a lifelong history of activism in New York Republican Party politics.

138 A perhaps unanswerable deep historical question is whether some of these men, and especially Helliwell, were aware that KMT profits from the revived drug traffic out of Burma were funding the China Lobby’s heavy attack on the Truman administration in general and on Dean Acheson and George C. Marshall in particular. (We shall see that in the later 1950s, Donovan and Helliwell received funds from Phao Sriyanon for the lobbying of Congress, supplanting those of the moribund China Lobby. Cf. Fineman, A Special Relationship, 214–15.) Citing John Loftus and others, Anthony Summers has written that Allen Dulles, before joining the CIA, had contributed to the young Richard Nixon’s first election campaign and possibly had also supplied him with the explosive information that made Nixon famous: that former State Department officer Alger Hiss had known the communist Whittaker Chambers (Anthony Summers with Robbyn Swann, The Arrogance of Power: The Secret World of Richard Nixon [New York: Viking, 2000], 62–63).

139 Sydney Souers (the first director, Central Intelligence Group, 1946) was born in Dayton, Ohio. Hoyt Vandenberg (director, Central Intelligence Group, 1946–1947) was born in Milwaukee, Wisconsin. Roscoe Hillenkoetter (the third and first director of the CIA, 1947–1949) was born in St. Louis. Walter Bedell Smith (the fourth director of the CIA, 1949–1953) was born in Indianapolis.

140 For the details, see Scott, The War Conspiracy, 261. The one from Boston, Robert Amory, was no less Social Register, and his brother, Cleveland Amory, wrote a best-seller, Who Killed Society, 1960).

141 Weiner, Legacy of Ashes, 52–53. It may be relevant that Bedell Smith himself was a right-wing Republican who reportedly once told Eisenhower that Nelson Rockefeller “was a Communist” (Smith, OSS, 367).

142 McCoy, The Politics of Heroin, 165–78; cf. Trento, The Secret History of the CIA, 71.

143 McCoy, The Politics of Heroin, 184.

144 Darrell Berrigan, “They Smuggle Drugs by the Ton,” Saturday Evening Post, May 5, 1956, 42.

145 “Thailand: Not Rogue Cops but a Rogue System,” a statement by the Asian Human Rights Commission, AHRC-STM-031-2008, January 31, 2008.

The potential for cooperation between the United States and Russia was demonstrated early on the morning of Oct. 28, when the first-ever joint effort of Russia’s Federal Drug Control Service, Afghanistan’s Ministry of Internal Affairs, and U.S. special forces in Afghanistan, ran a successful raid against heroin-producing laboratories in Nangarhar province, on the Afghanistan-Pakistan border.

At a joint Russian-U.S. press conference in Moscow the next day, Viktor Ivanov, head of Russia’s Federal Anti-Narcotics Committee, announced that over 932 kg—almost a ton—of heroin had been seized, enough for 200 million doses, worth $250 million, the Russian news agency Novosti reported. More importantly, the three heroin labs and one morphine lab all produced for a long-established drug-trafficking route into Pakistan, which was worth an estimated $1 billion to the drug trade, Novosti quoted Ivanov as saying.

But this raid, three months in preparation, after the Russian anti-narcotics service provided the coordinates for locating the labs to the U.S. Drug Enforcement Administration (DEA), is only a first, small step towards taking on what Ivanov rightly describes as the „monster“ of the Afghan dope cartels. It is an irony that the so-called „conflicts“ between Russia and the United States over dealing with Afghan opium, come from Russia’s repeated, specific demand that the DEA and the U.S. military in Afghanistan, act as they have in Colombia, by eradicating the drug crops, including with aerial spraying. Yet, the U.S./NATO International Security Assistance Force (IASF) has repeatedly refused to do just that.

Afghan opium production has exploded under Operation Enduring Freedom, Ivanov told Russia Today Oct. 8. Afghanistan produced about 7,000 tons of opium in 2009, enough to make 700 tons of heroin. This glut is so big, that Afghanistan exports less than half; there is far too much for the world’s drug addicts to consume. Russia and other countries estimate the stored drugs „at about 13,000-15,000 tons of opium,“ Ivanov said.

„So even if drug production stops in Afghanistan, it will still be able to supply the international market with heroin for another 20 or even 30 years….

„When the U.S. says you can’t deprive farmers of their livelihood, it actually sends a message to the Afghan leadership as well, saying they shouldn’t do it because, first, this will destroy people’s livelihoods and, second, you push farmers into the hands of the Taliban. I think this is merely an excuse.

„Since the U.S. special representative for Central Asia Richard Holbrooke first suggested, almost a year ago, this idea that instead of eradicating drug crops, the U.S. should target drug labs and traffickers, the number of labs producing drugs for Russia tripled. A year ago, we knew about 170 labs in Afghanistan; today, we know of more than 400 labs producing drugs for Russia.

„With more than 70% of coca crops eradicated in Colombia and only 3% [of opium] in Afghanistan, don’t you think this is a case of a double standard? In other words, it’s not that NATO cannot do it; they do it in one country, but for some reason they do not do the same thing in Afghanistan. When I visited the NATO headquarters in Brussels [on March 24] to address the Russia-NATO Council, I pointed out that more than 2,300 sq. km of coca crops are destroyed in Colombia annually. Yet only 20 sq. km of drug crops were destroyed in Afghanistan last year.“

Britain’s Dope, Inc.

The force behind this drug explosion is international organized crime, opium lords, including absentee plantation owners who live outside Afghanistan, and the international traffickers running a $500 billion dope trade. This force is a far greater strategic threat than insurgents in Afghanistan, who themselves are funded by the drug trade.

To put an even more precise label on the monster: It is the London-centered and British-run Dope, Inc. apparatus that is behind the opium and heroin explosion in Afghanistan. The greatest expansion of opium production in southern Afghanistan came after 2005, as British forces took charge of the ISAF mission in Kandahar and Helmand provinces. A number of reports have directly linked British forces in the region to heroin smuggling, and it was the British who most aggressively blocked the eradication programs, and made deals with opium lords and Taliban commanders.

As Lyndon LaRouche has repeatedly charged, the British puppet President, Barack Obama, has blocked any comprehensive anti-drug policy from being enacted. Factions in the U.S. government, including the military, who strongly support the Ivanov call for more joint U.S.-Russian collaboration against the opium scourge, have been forced to fly below the radar screen, or, as in the case of Gen. James Jones (ret.), the former National Security Advisor, have been purged altogether from the Administration.

Earlier this year, Secretary of State Hillary Clinton succeeded in funding a small-scale crackdown in Helmand province, conducted by the U.S. Marines, who replaced British troops in the area. But these rearguard efforts, including the recent joint Russian-American operation, will go no further so long as President Obama remains in office.

Drop in the Ocean

In Moscow Oct. 29, Ivanov announced that, „After we gave information to our U.S. and Afghan partners, the three sides planned the operation for three months. We used about 70 special forces units, three landing helicopters and six supporting ones…. The whole operation lasted less than four hours.“ He called the joint efforts of the anti-drug services, a good example of a „reset“ in relations between the two countries. Deputy Head of Mission of the U.S. Embassy in Russia Eric Rubin called the operation „a very concrete example of real cooperation. We cannot succeed alone. This was the first step and we will continue to destroy labs…. This problem [narco-trafficking] has been one of the biggest problems for both the U.S. and Russia and we can cope with it only by working together,“ he said, Xinhua reported.

However, Ivanov stressed, this raid was just a „drop in the ocean.“ Powerful and dangerous militarized drug cartels, similar to those in Mexico, have appeared in Afghanistan and the transit countries of Uzbekistan and Tajikistan. The scourge is taking a huge toll: Afghan narcotics killed some 100,000 people a year, 30,000 in Russia alone. Nine years after opium production exploded in the wake of the 2001 invasion, the „drug infrastructure in Afghanistan is expanding,“ Ivanov said in Moscow. The number of labs known to Russian intelligence alone, has risen almost 2.5 times in the past two years, from 175 in 2008, to 425 in 2010.

„We are interested in further cooperation in destroying drug laboratories. According to our sources, in Badakhshan alone, there are more than 400 drug laboratories, and a large number are located in Helmand. The number of labs is huge.“

Advisor to Russia’s Foreign Ministry Armen Oganesyan told Russia Today Oct. 29, that NATO’s reluctance to destroy the dope trade, allegedly because it would deprive Afghan peasants of work, „is insufficient, because we are talking about people’s lives.“ But the Oct. 28 raid sent a message to the drug lords, that NATO and Russia will work together and fight them, he said. „I think it is a very good start, on a very, very long road.“

The Nangarhar raid took place less than a week after Ivanov travelled to the U.S., visiting Washington D.C. and California. On Oct. 22, he met with Gil Kerlikowske, director of the U.S. Office of National Drug Control Policy, for the third session of the two nations‘ joint anti-drug task force. The Russian official has long been calling for military action in Afghanistan, as the only possible way to combat the strategic threat from the drug cartels; this time, inside the U.S., he went far beyond his previous statements, to confront the deliberate stonewalling of Obama Administration special envoy for Afghanistan and Pakistan, Richard Holbrooke, on any effective action against opium production.

„Holbrooke was a bit short of time,“ Ivanov told Foreign Policy, in an interview published Oct. 22. „We started the meeting with him; then he handed us to his deputy.

„The argument that now NATO and Holbrooke are using is that if we destroy poppy crops it will deprive peasants of their livelihood. It sounds so touching that they’re taking care of the peasants, but it’s not to be taken seriously,“ Ivanov said, mockingly. „Those peasants do not profit from poppy. They make, at most, $70 per year. Those who profit from it are the landlords living in Europe and America, and the Gulf countries. If we could give the land back to the Afghan government and provide these peasants with wheat, they could easily make their $70 a year growing wheat, not poppy.“

Taliban Not the Main Producer

Speaking in Washington D.C. Oct. 22, at a joint press conference after the meeting with Kerlikowske, Ivanov made the bitterly ironic point that „all the 150,000 [IASF] military personnel [are] employed in eliminating a mere 0.2% of the total illicit drug production“ in Afghanistan. „In August 2009, the U.S. Congress Foreign Relations Committee released a report titled ‚Drugs, Insurgency, and Terrorism,‘ [and] made an assessment of the volumes of illicit drug production by Taliban … at $150 million.“ Yet, „all Afghan drug production is estimated at $65 billion, so we can see the Taliban’s sector is only 0.2%. Obviously, it is not the main producer. The international forces say they will eliminate only the drug production related to the Taliban, in other words, all 150,000 personnel will be directed to eliminate just 0.2% of the drug production. The remaining 99.8% is left to be destroyed by Afghan forces.“

During the Taliban rule (1996-2001), which never succeeded in extending throughout Afghanistan, the opium production reached a record 4,000-plus tons, in 1999. The next year, Mullah Omar, the Emir of the Taliban, cracked down heavily on opium planting, and, as a result, in 2000, production dropped to about 500 tons. Omar had taken ruthless measures.

The IASF fear that eradication will drive masses of peasants into the arms of the Taliban is also absurd—only about 6% of the Afghan population make their living from opium, and this, under complete control of drug lords, the big plantation owners, and traffickers. If the drug lords‘ power were broken, the peasants could grow other crops, as Ivanov wrote in a commentary published Oct. 21 in the Washington Times.

„Stabilization and peace in Afghanistan can only be achieved through efforts that include a decisive fight against the production and trafficking of Afghan heroin,“ he wrote. „Drug money is seriously undermining international efforts to restore order in Afghanistan, and fueling terrorism elsewhere.“ U.S. national security is at stake, he wrote. „Among NATO countries, civilian deaths from a heroin overdose are 50 times the number of military casualties in the alliance operation in Afghanistan. Afghan heroin eventually ends up in the United States—ruining lives, devastating American families.“

Ivanov was sharply critical of the U.S. refusal to use aerial spraying to eradicate opium plantations, saying that the assumption that spraying would „alienate“ the population cannot be considered „convincing, moral or even accurate.“ While there is some progress in Russian-U.S. anti-drug cooperation, Ivanov wrote, „we still need to address the core of the problem: opium plantations.“

At the Foreign Press Center briefing, Ivanov made clear that Russian anti-narcotics forces grasp the importance of the financial side of the world opium trade. „Drug cartels and barons are major financial players,“ with the world drug trade being worth some $500 billion a year, Itar-Tass quoted Ivanov. Russia and the U.S. „agreed to exchange experiences related to the confiscation of property of incomes of people engaged in drug trafficking. The final goal of the drug business is to make profit, so it is an important task to expose financial traffic and the flow of money on bank accounts for the purpose of laundering,“ he said.

Kerlikowske expressed Washington’s policy, that the IASF-related anti-drug effort should focus on getting rid of drug labs in Afghanistan, while the local government should deal with the opium plantations. This means doing nothing, Ivanov responded. „The government of Afghanistan will hardly succeed in resolving the problem by itself,“ he told Russia Today in an interview Oct. 22. The „revenues from drug production are $65 billion, and the Afghan government’s annual budget is $12 billion, and 90% of this amount comes from financial aid. I will ask a rhetorical question: Can a government with such a small income deal with such a monster as the drug mafia?“

Going After the Labs and Landlords

As for dealing with the drug labs, Ivanov, who had served as an intelligence officer with the Soviet forces in Afghanistan, told the press that Russia has given the U.S. information on about 175 drug labs already. Ivanov told AP in an interview published Oct. 23, that he had provided details to U.S. officials in Kabul months ago, but DEA officials there have told him they are awaiting U.S. military approval to take down the labs. „For some reason they are unable to carry out any operations to destroy these laboratories, because there is a delay from the military side,“ Ivanov told AP. DEA officials also complain about a lack of equipment and fuel. „We will help them with fuel,“ Ivanov volunteered.

Ivanov said he also has suggested going after the big landlords in the opium poppy regions, by submitting their names to the UN for sanctions. „It wouldn’t be difficult to trace them,“ he said. He had discussed the issue with Holbrooke and other officials Oct. 21, but, he said, was frustrated because of U.S. adherence to the claim that eradicating poppy fields would send farmers into the hands of the Taliban. „It sounded not like constructive discussion but a manifestation of stubbornness,“ Ivanov said. „I cannot say they are not listening. They are listening very carefully and attentively. But unfortunately, there are no results.“

Ivanov had taken the unusual step of going to Los Angeles, he told Foreign Policy to speak out against the California ballot initiative, Prop 19, to legalize marijuana. „I hadn’t known about it before, and I was absolutely shocked when I was in the city and saw these posters saying that you can get marijuana for medical purposes,“ he said. „Medical“ marijuana is already legal in the state! Ivanov met with Los Angeles Mayor Antonio Villaraigosa and Sheriff Leroy Baca to voice Russia’s opposition to the measure.

„I’m afraid that the consequences of [legalization] will be catastrophic. Even the Netherlands, where they sell marijuana legally in coffee shops, they are now reversing on this. Because there, and everywhere, drug addiction is becoming stronger, and the people who are addicted develop psychiatric deviations. They say, ‚What does God do when he wants to punish a person? He deprives him of his mind.‘ “

 

Attention, the source is: http://www.larouchepub.com/other/2010/3743us_rus_wodrugs.html

Statistics say that by the year 2020 the number of individuals over age 50 who are in need of rehab will be at least five times higher than it is today in 2010.

The use of heroin got its start with the baby booming population, as did many other illegal drugs. Scientists believe without hesitation that these individuals will continue to abuse heroin well into their golden years. This not only poses a problem for the senior citizen who has to check into rehab because the heroin use is effecting their blood pressure, blood thinning, cardiac medications and whatever other medications they are using to sustain their life a bit longer. It is also going to affect the health care system greatly. As well, know rehab is not covered by everyone’s insurance and the cost is of rehab can be outrageous.

Many of the baby booming heroin abusers are also abusing opiates for chronic pain or pain management. “Physical decline, loss of friends or loved ones, and decreasing independence can contribute to late-onset addiction — but the startling phenomenon in older adult heroin use is the existence of the lifetime user.” Therefore, those who did not abuse heroin throughout their young and middle adulthood they have started now as senior citizens for numerous reasons as stated above.

 

source: http://www.addictioninfo.org/news/heroin-addiction/baby-boomers-heroin-use-a-growing-problem

Opiate abuse is among the top abused drugs and has an extremely high rate of mortality. Death is most often caused by overdose. Like many drugs over time use and high doses the body starts to tolerate the drug and the drug in this case opiates become less effective. Therefore, the user increases the dose to receive the same effect it once had. Unfortunately, that “feeling” the abusers are looking for requires more opiates than their body can handle and the end result is death.

Collected Data

“Information on 5,577 patients who had a substance abuse diagnosis and received 267,003 OST prescriptions during 1990-2005 was evaluated. These patients were followed up until one year after the expiry of their last OST prescription, or the date of death. The researchers looked at mortality rates comparing periods in and out of treatment programs compared with the general population. A total of 178 (3%) patients died either on treatment or within a year of their last prescription. The rate of death amongst people off treatment was almost double that of people taking treatment.”

Clinical Study of OST (Opiate Substitution Treatment)

During the first two week period of the year long study the mortality rate was the at 1.7%. When the study ended, the researchers found that the patients morality rate immediately following the end of the OST was almost nine times higher than when they started the study.

The Good News

The OST has an 85% chance of greatly reducing opiate abuse and patients who stay with the one year program have an 85% chance or higher of avoided an early death.

Conclusion quote „Clinicians and patients should be aware of the increased mortality risk at the start of opiate substitution treatment and immediately after stopping treatment. Further research is needed to investigate the effect of average duration of opiate substitution treatment on drug related mortality.

source: http://www.addictioninfo.org/news/drug-addiction/opiate-substitution-treatment-ost

Summary

This survey investigated the current practices and challenges of physicians treating opioid dependence in Germany, France, Italy and
the UK. Doses favoured in Europe appeared to conflict with recommended best practice, with low mean methadone and buprenorphine
maintenance doses reported (44.3 and 9.5 mg, respectively). Mean time to buprenorphine maintenance doses was longer than recommended
at 14.4 days. Respondents also rated diversion and misuse management as their most difficult challenge in treating opioid
dependence. These data suggest that prescribing practices are likely to increase this problem, as well as impeding treatment success
by decreasing compliance and retention.

 

A lot of Theory but good: Bacha et al 12(3)2010

Opium markets, located throughout Afghanistan and along major transit routes, are where traders can sell raw opium and obtain precursor chemicals and other supplies for refinement (morphine base and heroin). Refinement workshops are located in areas typically situated near unofficial border crossing points, near poppy farms, extremely isolated locales, or areas where governance is weak and instability is high (Figure 1). Refinement workshops are fairly crude and can be contained within two rooms of any given compound. Metal drums, wood‐fire stoves, and simple iron presses (car jacks) are typical instruments used in basic processing. Some reports suggest foreign chemists, such as Iranian, Turkish and Pakistani nationals, provide technical assistance, particularly when it comes to further refining morphine base into heroin.

Heroin laboratories are restricted to ungoverned areas near the border with Pakistan, such as Helmand’s Dishu district and Nangarhar’s Achin district. Mobile labs have been reportedly used in both Helmand and Nangarhar and consist of gas fired stoves attached to the back of large trucks. It takes about seven kilograms of Afghan opium to make one kilogram of morphine base. The conversion rate of morphine base to heroin is 1:1.
The UN suggests 70% of these labs are present in only three provinces: Helmand (23), Nangarhar (25), and Badakhshan (14).2 Additionally, the UN estimates two‐thirds of all Afghan opiate exports are now refined into morphine base or heroin domestically before leaving the country.3 Traditionally, Afghan opium would be sent to Pakistan, Iran or smuggled to Turkey via Iran for further processing. Pakistan launched a major crackdown against such facilities in the FATA area in 1995, systemically destroying hundreds of illicit drug processing workshops and forcing the industry westward into Afghanistan. In 2007, UN analysts compiled a list of the main heroin/morphine processing locations in Afghanistan. Two years ago, all of Nangarhar’s twenty‐five processing laboratories were located in the Achin district.

In southern Helmand, the massive smuggling hub of Baramcha in neighboring Pakistan (Baluchistan’s Chagai district), serves as a mega‐heroin producing center, with capabilities of processing industrial quantities of morphine base and heroin. The undisputed kingpin of Baramcha, a Baluch named Haji Juma Khan, was arrested by authorities in Jakarta, Indonesia in late October 2008 after arriving on an international flight from Dubai. Khan is believed to have orchestrated his powerful drug trafficking network since at least 1999. Prior to his arrest, Khan maintained links with the Taliban, al Qaeda and with commanders loyal to warlord Gulbuddin Hekmatyar.
Following his arrest, US authorities extradited Khan to New York and charged him with several counts of narco‐terrorism. Intelligence and eyewitness testimony has linked Khan to the November 19, 2007 suicide bombing that killed six bodyguards and the son of Nimroz provincial governor Dr. Ghulam Dastagir. Khan is also suspected of providing a payment to insurgents for the deadly January 8, 2008 complex assault and suicide bombing launched against the five‐star Serena hotel in Kabul that left eight people dead, including a US citizen. Khan remains in US custody and is awaiting trial in New York.
Helmand remains the most pivotal cog in the Afghan drug machine; producing 66% of the country’s poppy output in 2008 alone. Poppy cultivation, processing, and smuggling have seriously plagued the Afghan government’s legitimacy and ability to govern in southern Afghanistan. Rampant corruption and a tidal wave of domestic drug abuse are only part of the social erosion caused by the illicit drug industry. Provincial officials have recently stated nearly 60% of Helmand’s police force abuse drugs and that there are at least 70,000 addicts now living in Helmand.5 Insurgents have firmly aligned themselves with traffickers in Helmand, coordinating ambushes, and roadside bomb and suicide attacks against eradication personnel. (see below)
In Badakhshan province, scores of open air refinement and processing workshops dot the rugged countryside. Although the UN has identified 14 such laboratories operating in Badakhshan, Tajik officials believe at least 80 such facilities exist.6 In March 2009, Afghan counternarcotics police raided a heroin lab in Badakhshan’s Argo district, arresting one suspected traffickers and confiscating 24 cans of heroin, seven gas cylinder (for stove), 15 bottles of acid, two power generators and some other materials using for making heroin, according to a report filed by Pajhwok Afghan News. 7 Other processing locations in the Argo district include the villages of Barlasi Chinar, Nem Tala and Turok.8
Attacks against Eradication and Counternarcotics Personnel
In 2007, armed farmers caused most of the violence recorded against eradication teams and counternarcotics personnel according to the UN. Sixteen recorded security incidents against eradication teams were recorded in seven provinces: Nangarhar, Kandahar, Farah, Laghman, Helmand, Badghis and Badakhshan. 15 policemen and four farmers died in the attacks and 31 others suffered serious injuries. Eradication equipment, such as tractors used to crush the poppy plants, were also targeted. At least ten tractors used by eradication teams were set on fire and destroyed during the 2007 campaign.
In 2008, the UN recorded 78 fatalities caused by “mine explosions, gun attacks, and suicide bombings targeting eradication teams and counternarcotics personnel,” an increase of about 75% if compared to the 19 deaths in 2007.9 Attacks took place in Helmand, Kandahar, Herat, Nimroz, Kapisa, Kabul and Nangarhar provinces. One of the deadliest attacks occurred in Nangarhar on April 30, when a Taliban suicide bomber detonated at the Khogyani district headquarters killing 19 people, including the district police chief and scores of counternarcotics policemen.10 Fazal Ahmad, a MCN/UNODC surveyor who was collecting narcotics data for the 2008 Opium Survey, also died in the blast.
The trend of criminals supporting or facilitating attacks against eradication personnel and government targets by outsourcing to insurgent factions such as the Taliban has continued in 2009. By mid‐April 2009, three suicide attacks (one unsuccessful) targeting counternarcotics headquarters and staff throughout southwestern Afghanistan left 16 people dead and 55 wounded. Below is a summary of the most high profile narco‐terrorist attacks against counternarcotics personnel in 2009:
April 10, 2009: A Taliban suicide bomber detonated at the police headquarters in Lashkar Gah killing two policemen and three civilians, two of them children. Over 17 others were wounded including four policemen. “This attack is a joint struggle of smugglers and the Taliban against anti‐narcotics forces,” provincial official, Dawoud Ahmadi, told reporters. “We have launched a poppy‐eradication campaign,and they want to stop or weaken the campaign in the province.” Additionally, three cars and a tractor were destroyed in the attack. 11
March 16, 2009: A Taliban suicide bomber dressed in a police uniform approached a team of counternarcotics officers at the Lashkar Gah police headquarters and detonated himself, killing eight police officers and two civilians. The deadly blast left 31 others wounded.
March 8, 2009: Unidentified gunmen assassinated a policeman in the northern province on Baghlan. Local officials blamed the Taliban, saying the Taliban killed Naqibullah after discovering he worked with provincial counternarcotics personnel. The Taliban denied involvement in the killing.1
February 23, 2009: A Taliban suicide bomber detonated himself outside the gate of the counternarcotics police headquarters in Zaranj, the provincial capital for Nimroz province. The blast killed one police officer and injured seven others including three civilians. A second suicide bomber dressed in a police uniform was shot and killed by police. A third would‐be bomber managed to escape

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DUBAI (AlArabiya.net)Reports of secret hangings and mass executions in Iranian prisons raised concerns among human rights groups about undeclared abuses committed in the world’s second biggest executioner after China.

The International Campaign for Human Rights in Iran (ICHRI), an NGO based in New York and the Netherlands, sounded alarm bells over undeclared executions, many taking place in groups, carried out at the Vakilabad Prison in the eastern city of Mashhad, the UAE daily The National reported Sunday.

According to the ICHRI’s statement, based on the testimony of former prison inmates, prisoners are in many cases executed in groups and the last mass execution took place on October 12 when ten prisoners were executed together. A former inmate told the ICHRI that he was witness to 46 executions in one day in October 2009.

According to Ahmad Ghabel, a religious scholar who spent three months at Vakilabad Prison earlier this year, at least 50 executions took place during his detention.

Ghabel, who was released on bail then detained again for speaking about Vakilabad executions in public, said the government does not release accurate figures of hangings and never acknowledges secret executions to avoid international outrage.

More than 600 inmates are currently awaiting execution in various Iranian prisons mainly for drug trafficking. The city of Mashhad is a major smuggling hub for heroin coming from Afghanistan.

Executions on the rise

We are concerned that if these executions are, in fact, taking place in Mashad, then are other prisons executing in secret also 

ICHRI spokesman Aaron Rhodes

Testimonies by former inmates indicate that the numbers of executions in Iran double from last year’s figure, said ICHRI spokesman Aaron Rhodes.

“We are concerned that if these executions are, in fact, taking place in Mashad, then are other prisons executing in secrecy also?” he said in a phone interview from Hamburg, Germany.

“The authorities are trying to curb these problems by using extreme punishments, which violate Iranian and international law, in an increasingly brutal policy of intimidation.”

Similar testimonies by Iran former Vakilabad prisoners and their families have been investigated by Amnesty International (AI). Although the findings are not yet completed, AI experts argue that reports of secret executions are true.

“We regard these allegations as credible,” said Drewery Dyke, a London-based expert on Iran in an interview.

According to analysts, the surge in execution rates reflects hardliners’ dominance in Iran’s judiciary. Imposing the capital punishment has also been recently accompanied by a rise in the use of torture in Iran’s prisons.

Statements by Iranian judges serve to highlight the growing tendency towards violent punishments. A few days ago, Ebrahim Raisi, Iran’s deputy judiciary chief praised the recent amputation of a thief’s hand as a “divine punishment” and “source of pride.”

A senior analyst in Tehran, who spoke on condition of anonymity, said that new judiciary chief Sadegh Larijani, contrary to his predecessor, does not promote the reduction of executions especially in drug offences.

Secretive procedures

According to the ICHRI report, executions are carried out in the most secretive manner. The majority of prisoners get to know they would be executed only a few hours before. Neither their families nor their lawyers are notified and prison phone lines are disconnected in order to avoid leaks.

Under Iranian law, families of prisoners are to be informed of the time of the execution in order to visit the prisoner or be present at the hanging.

Names of the condemned are announced over a microphone after making sure prisoners are inside their cells then prisoners to be executed are taken from their cells to write their wills and undergo a religious cleansing ritual.

After the execution, the prison notifies the deceased’s family and they are allowed to retrieve the body after paying for the rope used in the hanging, a former prisoner told ICHRI.

The stance of the Iranian authorities towards secret executions, observers argue, is quite ambivalent. While information about executions is treated as highly confidential, the regime does not mind occasional leaks that they believe have a deterring effect.

Death penalty and drugs

According to multiple accounts, the majority of inmates on death row were convicted for narcotics-related crimes 

ICHRI statement

In Iran, offences punishable by death include murder, rape, drug trafficking, armed robbery, adultery, treason, and espionage and the capital punishment is seen by the authorities as essential for preserving national security.

“According to multiple accounts, the majority of inmates on death row were convicted for narcotics-related crimes,” said the ICHRI. “Some reported that they were tortured and forced to make confessions, but that trial judges ignored their claims of physical coercion.”

Despite government claims to the contrary, human rights groups say that prisoners accused of drug offences are detained for a long time before the trial, allowed limited access to lawyers, and subjected to physical abuse.

Drug trafficking ranks first amongst Iran’s capital offences and clashes between security officers and more than 3,500 officers were killed in the past two decades in clashes with drug smugglers on the border with Afghanistan.

Iran is believed to have the world’s highest addiction to opium and heroin, which are usually available in cheap prices after failing to reach Europe from Afghanistan. Analysts argue that unemployment and social problems contribute to the rise in addiction rates.

At least 388 were executed last year, which makes Iran the world’s second in executions after China. In 2005, the year President Mahmoud Ahmadinejad assumed power, the number did not exceed 85.

Ein Molekül kann einfach gebaut sein und trotzdem komplexe Wirkung entfalten. Ketamin ist ein Beispiel mit vielseitiger Verwendung. Hilft das Narkotikum vielleicht sogar gegen Depressionen?

 

Ketamin: Dieses amerikanische Präparat ist offiziell nicht für Menschen gedacht

Ketamin: Dieses amerikanische Präparat ist offiziell nicht für Menschen gedacht

20. Oktober 2010

Seinen Aufenthalt im Krankenhaus wird Bradley Weafer nicht so schnell vergessen, auch wenn der neun Jahre zurückliegt. Im August 2001 wurde der Sozialarbeiter im Krankenhaus von Vancouver am Rücken operiert. Die Ärzte gaben ihm Ketamin. Woraufhin dem 38-Jährigen mehr als schwummrig wurde: Er hatte das Gefühl, mit den Füßen voran in einen schwarzen Tunnel gesaugt zu werden. Von da aus sei er geradewegs in den Himmel geschossen, wo er von einer Gestalt, groß wie ein Hochhaus, geblendet und wieder hinab in den Abgrund geschleudert worden sei.

„Ich sah Gott und musste um mein Leben kämpfen“, erzählte Weafer später vor Gericht. Das habe ihn dauerhaft traumatisiert. In zweiter Instanz wurden dem Kanadier 63.000 Dollar Schmerzensgeld zugesprochen.

etamin dient im Krankenhausalltag normalerweise nicht zur unfreiwilligen Erleuchtung, sondern zur Anästhesie. Als Narkotikum wirkt Ketamin rasch und zuverlässig, der Schluckreflex bleibt erhalten, gleichzeitig werden Atem und Kreislauf stimuliert. Es gehört zur Standardausrüstung von Notfallärzten. Eine Betäubung unter Ketamin klingt schnell ab, weshalb sie gern vor kleineren Eingriffen oder schmerzhaften Untersuchungen gegeben wird.

Wären da nicht die Nebenwirkungen

Ketamin ist sogar in der Kindermedizin zugelassen. Selbst bei zehnfacher Überdosierung wurden bislang keine Folgeschäden beobachtet. Auch Veterinärmediziner setzen es häufig ein; die „Hellabrunner Mischung“ beispielsweise, die zur Fernbetäubung von Zootieren entwickelt wurde, enthält zur Hälfte Ketamin. Ein vielseitig verwendbarer Stoff. Wären da nicht die Nebenwirkungen.

Schätzungsweise zwölf Prozent aller Patienten zeigen nach einer Ketaminbetäubung unerwünschte Aufwachreaktionen. Sie berichten von Visionen und anderen bizarren Erlebnissen. Die Fachliteratur spricht von „psychomimetischen Effekten“. Zur Dämpfung wird unter anderem Valium verabreicht.

Für seine halluzinatorischen Begleiterscheinungen ist der Stoff berüchtigt: Unter dem Namen „Special K“ kursierte Ketamin im Vietnamkrieg. Seit Anfang der achtziger Jahre zählt es neben Ecstasy, Speed oder Kokain zu den typischen Partydrogen. Man hätte die Substanz längst geächtet und aus dem medizinischen Verkehr gezogen, wenn sie nicht gleichzeitig so erstaunliche Eigenschaften hätte.

Die Suche nach der Morphium-Alternative

PubMed, die größte öffentlich zugängliche biomedizinische Datenbank, liefert zum Stichwort Ketamin über 11.000 Fundstellen. Immer mehr Autoren widmen sich neuerdings der Frage, ob man Ketamin nicht zu therapeutischen Zwecken einsetzen sollte. Denn im Gehirn wirkt es anders als alle bislang gebräuchlichen Psychopharmaka.

Ketamin ist ein Produkt der Suche nach Alternativen zum Morphium. Das im Opium enthaltene Alkaloid, gewonnen aus dem Milchsaft des Schlafmohns, gilt als eines der stärksten Schmerzmittel überhaupt. Sein Suchtpotential allerdings ist erheblich. In Deutschland ging man deshalb schon gegen Ende des 19. Jahrhunderts daran, synthetische Abkömmlinge zu entwickeln. Eine Zeitlang galt Heroin als Favorit, bis sich herausstellte, dass es noch schneller süchtig macht. Die Farbwerke Hoechst synthetisierten eine ganze Reihe von Stoffen, unter anderem Metamizol („Novalgin“), das bis heute verschrieben wird. 1939 kam das erste vollsynthetische Opioid Pethidin (Handelsname Dolantin) auf den Markt. Im gleichen Jahr gelang den Hoechst-Chemikern die Synthese der Ersatzdroge Methadon, die von Hitlers Militärärzten als kriegswichtig eingestuft wurde, aber nicht mehr in nennenswerten Mengen zum Einsatz kam.

Die Patentrechte daran sicherten sich die Amerikaner. Ein Zentrum für Forschungen an synthetischen Schmerz- und Betäubungsmitteln entstand an der University of Michigan in Ann Arbor. Dort arbeiteten die Pharmazeuten eng mit dem Arzneimittelhersteller Parke-Davis zusammen.

Kein Psychopharmakon ist vor Missbrauch gefeit

Ein erster aussichtsreicher Kandidat war Phenylcyclohexylpiperidin, abgekürzt PCP. Unter der Studiennummer CI-395 wurde es an Mäusen und Ratten getestet – sie reagierten erregt. Tauben dagegen verfielen in kataleptische Starre, Hunde wiederum ins Delirium. Affen allerdings ließen sich zuverlässig anästhesieren. Versuche an Menschen folgten. Einige Patienten berichteten nach der Narkose von verwirrenden Zuständen. Psychiater erkannten darin Symptome eines akuten schizophrenen Schubs. PCP wurde offiziell fallengelassen. Auf dem illegalen Markt machte es anschließend unter der Bezeichnung „Angels Dust“ Drogenkarriere.

Es war nicht das erste und nicht das letzte Mal, dass eine an sich vielversprechende Substanz in die falschen Hände geriet. Vor Missbrauch ist kein Psychopharmakon gefeit – schließlich soll es die Stoffwechselvorgänge im Gehirn beeinflussen. Dazu muss es in Wechselwirkung treten mit Stoffen und Rezeptoren, die Lust oder Leid, Euphorie oder Depression, Realität oder Illusion vermitteln. Psychopharmaka sind dadurch definiert, dass sie die Hirnchemie verändern. Eine Substanz, die dort nicht eingreift, wäre keine, die man gegen Gemüts- oder Bewusstseinsstörungen einsetzen könnte.

Die Pharmakologen in Arbor wurden jedenfalls zurück ins Labor beordert, um ein Produkt mit ähnlich betäubender Wirkung wie PCP, aber geringeren psychischen Nebenwirkungen zu finden. Es dauerte nicht lange, und sie hielten ein Derivat mit der Summenformel C13H16ClNO in den Händen, chemisch gesehen ein Abkömmling des Cyclohexans. Sie tauften es Ketamin. Unter der Nummer CI-581 ging es in die Prüfung.

Dissoziative oder einfach psychedelisch?

Die Firma Parke-Davis unterhielt damals ein eigenes Labor im Staatsgefängnis von Jackson. Häftlinge bekamen zwischen 35 Cent und 1,25 Dollar, wenn sie sich an medizinischen Tests beteiligten. Der Anästhesiologe Edward Domino berichtet, wie er am 3. August 1964 zum ersten Mal einem Strafgefangenen Ketamin injizierte. Erst hatte dieser das Gefühl, „irgendwie breit zu sein“. Dann stellten sich lebhafte Träume ein. Die Versuche wurden fortgeführt. Etwa ein Drittel aller Probanden berichtete nach dem Aufwachen von seltsamen Erlebnissen; die meisten hatten den Eindruck, ihren Körper zu verlassen und weit draußen im All zu schweben.

„Das machte die Leute von Parke-Davis natürlich nervös“, erinnert sich Edward Domino, „wenn die Begleiteffekte als schizophrenieähnlich beschrieben worden wären, hätten wir die Sache sofort beerdigen können.“ Bei der Veröffentlichung der Daten einigte man sich schließlich auf die Definition, Ketamin sei ein „dissoziatives Anästhetikum“. Also eines, das nicht nur Schmerzempfinden und Bewusstsein ausschaltet, sondern zur veränderten Wahrnehmung der eigenen Identität führen kann. Bei dieser Bezeichnung ist es geblieben. Es hätte allerdings wenig dagegen gesprochen, Ketamin psychedelische Eigenschaften zu bescheinigen.

Das ist unter anderem auch eine Frage der Weltanschauung. Franz Vollenweider, Leiter einer Forschungsgruppe für Experimentelle Psychopathologie an der Psychiatrischen Universitätklinik Zürich, hat sich viele Jahre lang mit halluzinogenen Substanzen beschäftigt. In Nature Reviews Neuroscience warb er im August für eine vorurteilsfreie Herangehensweise. Ketamin gehört für Vollenweider ebenso wie Psilocybin oder Meskalin zu den aussichtsreichen Kandidaten eines psychedelischen Therapieansatzes. Er knüpft damit an eine Tradition an, die schon abgerissen schien.

Einen großen Bogen um alle einschlägigen Substanzen

Noch in den fünfziger Jahren ruhten große Hoffnungen auf den Psychedelika. Viele glaubten, die dadurch ausgelösten Modellpsychosen würden wertvolle Hinweise auf die Entstehung von Nervenkrankheiten liefern. Teilweise wurden die Arbeiten sogar vom amerikanischen Geheimdienst finanziert; die CIA ließ umfangreiche Testreihen mit Lysergsäurediethylamid (LSD) durchführen, in der Hoffnung, eine Methode zur chemischen Gehirnwäsche zu finden. Studienobjekte, an denen die „Atombombe des Geistes“ erprobt wurde, waren unter anderem Soldaten, Strafgefangene, ahnungslose Krankenhauspatienten und Studenten.

Öffentlich bekannt wurden vor allem die Experimente des Harvard-Psychologen Timothy Leary. Sie sorgten freilich auch dafür, dass die ganze Forschungsrichtung ins Abseits geriet. Anfangs hatte er gezielt versucht, jugendliche Kriminelle durch Psilocybin-Trips von der schiefen Bahn abzubringen. Später ging er dazu über, Halluzinogene wahllos zu propagieren. Als Befürchtungen laut wurden, die Sowjetunion könne in einem psychochemischen Erstschlag das Trinkwasser Amerikas mit LSD versetzen, schrieb Leary im Bulletin of the Atomic Scientist, man solle sich rechtzeitig vorbereiten und schon mal ausprobieren, wie bereichernd so ein Trip sei. Das war dann das Ende seiner akademischen Laufbahn.

Der legale Umgang mit Lysergsäurediethylamid und seinen Verwandten ist seit Ende der sechziger Jahre fast vollständig unterbunden worden. Medizinische oder psychologische Versuche hat es kaum noch gegeben. Die meisten Forscher machen bis heute einen großen Bogen um alle einschlägigen Substanzen. Was auch für Ketamin zutrifft: Wer möchte schon mit einer Droge in Verbindung gebracht werden, von der es unlängst hieß, sie würde ausgeflippte Jugendliche dazu bringen, auf Mallorca-Partys reihenweise vom Balkon zu springen?

Zugleich streng kontrolliert und unverzichtbar

Edward Domino hat den Stoff, den er entdecken half, mit einem wilden Tiger verglichen. Er und seine Kollegen arbeiteten in den siebziger Jahren daran, das Raubtier medizinisch zu zähmen. Die unerwünschten Aufwachreaktionen ließen sich am ehesten durch Tranquilizer unterdrücken. Doch Ketamin hatte den Laborkäfig längst verlassen.

1978 erschien ein Erfahrungsbericht des Psychiaters John Lilly, der sich in einem aberwitzigen Selbstversuch über Jahre hinweg täglich immer größere Ketamindosen gespritzt hatte und darüber offensichtlich paranoid geworden war. Seine Schilderungen verbreiteten sich über die kalifornische Esoterikszene hinaus. Obwohl er Nachahmer ausdrücklich warnte, kam es zu Todesfällen. Die Droge wurde unter den Substanzen aufgenommen, die trotz anerkannter medizinischer Indikation streng kontrolliert werden.

So steht Ketamin heute ebenso unter Vorbehalt des amerikanischen „Controlled Substances Act“ wie auf der Liste der unverzichtbaren Arzneistoffe der Weltgesundheitsorganisation. In Deutschland ist Ketamin verschreibungspflichtig, fällt aber nicht unter das Betäubungsmittelgesetz. Schlagzeilen machte der Stoff zuletzt, als im September 2009 zwei Teilnehmer einer „psycholytischen Therapiesitzung“ unter Anleitung eines Berliner Arztes starben. Er wurde zu knapp fünf Jahren Haft verurteilt. Sein Lehrmeister, der Schweizer Psychiater Samuel Widmer, praktiziert weiter. Der selbsternannte Gründer einer „tantrisch-spirituellen Universität“ hält Ketamin und ähnliche Substanzen für „Sakramente“. Allerdings distanziert sich inzwischen selbst die Schweizerische Ärztegesellschaft für psycholytische Therapie von ihrem ehemaligen Mitglied.

Depressive – ein gewaltiger Markt

Die Ahnenreihe der Forscher, die bislang auf die therapeutische Kraft von Psychedelika setzten, wirkt insgesamt wenig vertrauenerweckend. Hat ein Stoff wie Ketamin da überhaupt ernsthafte Chancen? In den Augen der Pharmahersteller schon. Allein die Datenbank ClinicalTrials listet 15 aktuelle Studien der Phasen I bis IV auf, die sich der Frage widmen, ob Ketamin bei psychischen Störungen helfen könnte. An erster Stelle steht die Suche nach einem Mittel gegen behandlungsresistente Depressionen. Angesichts der Tatsache, dass in den Industrienationen durchschnittlich zehn Prozent der Bevölkerung im Laufe ihres Lebens depressive Symptome entwickeln und fast die Hälfte davon nicht auf die verfügbaren Pharmaka ansprechen, wäre das ein gewaltiger Markt.

Ein neuer Behandlungsansatz ist ohnehin überfällig. Lange Zeit dachte man, bei der Depression handele es sich um eine Art Mangelerscheinung. Nach dieser immer noch gültigen Lehrmeinung werden Glücksgefühle durch Botenstoffe hervorgerufen; wer zu wenig davon produziert, verfällt automatisch dem Trübsinn. Kritiker haben eingewendet, das sei in etwa so, als wolle man die Anwesenheit von Schmerz durch akuten Aspirinmangel erklären.

Doch die Theorie von den Botenstoffen war bislang die einzige, die brauchbare Resultate lieferte. Als genuiner Saft der Freude galt zunächst das Noradrenalin, ein blutdrucksteigerndes Hormon, das in der Nebenniere gebildet wird und im Gehirn als Neurotransmitter fungiert. Später gesellten sich Dopamin und Serotonin hinzu; alle drei Substanzen gehören chemisch zur Gruppe der Monoamine. Praktisch alle Antidepressiva, die im Lauf eines halben Jahrhunderts entwickelt wurden, zielen darauf ab, die Konzentration dieser drei Stoffe im Gehirn zu erhöhen. Doch nur bei gut der Hälfte aller depressiven Patienten führt das zur Heilung. Und wenn, dann vergehen Wochen bis Monate. Selbst moderne Wirkstoffe wie die sogenannten selektiven Serotonin-Wiederaufnahmehemmer erhöhen zwar in Minutenschnelle die Konzentration des Botenstoffs an den Synapsen der Nervenzellen – der gewünschte Effekt lässt trotzdem wochenlang auf sich warten. Es passt auch nicht ins theoretische Bild, dass manche Mittel gerade dadurch antidepressiv wirken, dass sie die Konzentration der genannten Botenstoffe herabsetzen.

Eine ganze Kaskade biochemischer Ereignisse im Gehirn

„Wir waren zu sehr auf die Monoamine fixiert“, findet der Neuropsychiater Hussein Manji vom National Institute of Mental Health (NIMH), „das hat unser Verständnis für die biologischen Grundlagen von Gemütsleiden nicht gerade vorangebracht.“

Viele Forscher glauben heute, Noradrenalin, Serotonin oder Dopamin würden längerfristig nur auf dem Umweg über weitere Wachstumsfaktoren („brain-derived neurotrophic factors“) dazu beitragen, die Aktivität bestimmter Hirnareale anzuregen. Seit einigen Jahren rückt deshalb ein bekannter, aber bisher vernachlässigter Stoff ins Blickfeld. Es handelt sich um Glutamat, dem Laien in seiner Eigenschaft als Geschmacksverstärker aus dem Chinarestaurant bekannt. Glutamat, oder exakter: Glutaminsäure, spielt im Stoffwechsel des Körpers eine zentrale Rolle. Im Gehirn tritt sie in Wechselwirkung mit NMDA-(N-Methyl-D-Aspartat)-Rezeptoren. Und genau an denen greift auch Ketamin an: Es ist ein Gegenspieler des NMDA-Rezeptors, es blockiert ihn und löst dadurch eine ganze Kaskade biochemischer Ereignisse im Gehirn aus. Wo und mit welchen Folgen – das wird erst jetzt deutlich.

Schon Edward Domino hatte anekdotische Hinweise darauf gefunden, dass Ketamin gegen affektive Störungen wirken könnte. Eine seiner Patientinnen war danach süchtig geworden, nachdem die üblichen Antidepressiva versagt hatten. Domino ging der Sache nicht weiter nach. Eine Arbeitsgruppe um den Psychiater John Krystal von der Yale University in New Haven griff die Idee zwanzig Jahre später auf: Sie injizierten einer kleinen Gruppe von schwer depressiven Patienten geringe, deutlich unterhalb der Anästhesieschwelle liegende Dosen von Ketamin. Der Effekt war umso größer: Innerhalb von 72 Stunden verbesserte sich deren Zustand so weit, dass die behandelnden Ärzte es kaum glauben konnten.

Anhaltende Kettenreaktion nach einmaliger Dosis?

Ähnliche Befunde hatte es gelegentlich schon gegeben; chronische Schmerzpatienten berichteten, dass nach Ketaminbehandlung nicht nur ihre Qualen nachgelassen hatten, sondern auch die damit einhergehenden depressiven Anwandlungen. Ursache und Wirkung waren in diesem Fall jedoch nicht auseinanderzuhalten. Die Yale-Forscher lieferten die erste placebokontrollierte Studie, bei der weder Ärzte noch Patienten wussten, wer das Medikament erhielt. Die Dosis war bewusst so niedrig gewählt, dass sich die verräterischen Psychoerscheinungen nach Möglichkeit nicht bemerkbar machten.

Andere Teams wiederholten die Versuche in etwas größerem Rahmen. Sie stellten unter anderem fest, dass die antidepressive Wirkung einer einzigen Ketaminspritze innerhalb von zwei Stunden einsetzt und bis zu zwei Wochen anhalten kann, mit einer Erfolgsrate, die herkömmliche Mittel in den Schatten stellt. Die meisten Patienten hatten nicht mehr auf die üblichen Antidepressiva angesprochen. Im August dieses Jahres wurde in den Archives of General Psychiatry eine weitere Studie vorgestellt, nach der Ketamin äußerst rasche Wirkung auch in den besonders schwer therapierbaren depressiven Phasen einer bipolaren Erkrankung zeigt. Mehr als die Hälfte der betroffenen Patienten hatte nicht einmal mehr auf Elektroschocks angesprochen; sie gelten in solchen Fällen als Mittel letzter Wahl. „Ein derart dramatischer Effekt einer einzigen Behandlung ist bei schweren Depressionen noch nie beobachtet worden“, fasst der Psychopharmakologe Carlos Zarate vom NIMH die Ketamin-Ergebnisse zusammen.

Wie aber kann ein Stoff, der nur eine biologische Halbwertszeit von wenigen Stunden im Körper hat, derart einschneidend wirken? Möglicherweise setzt schon die einmalige Gabe von Ketamin eine anhaltende Kettenreaktion in Gang, durch die bestimmte Nervenverbindungen neu geknüpft oder beschädigte wiederhergestellt werden. In Experimenten an Ratten hat Ronald Duman, ein Kollege von John Krystal in Yale, vor kurzem eine wichtige Station auf diesem Weg ausfindig gemacht: Es handelt sich um ein bereits bekanntes, in allen Säugetieren vorkommendes Enzym („mammalian target of rapamycin“, mTOR), das die Synthese von Eiweißstoffen kontrolliert, die bei der Bildung neuer Nervenkontakte benötigt werden.

Die unerwünschten Nebenwirkungen

„Ketamin wirkt geradezu magisch“, schwärmte Duman, als seine Studie Mitte August in Science erschien. Wenn es um den Einsatz beim Menschen geht, wäre vielen allerdings wohler, wenn weniger Magie im Spiel wäre. In der Praxis wird deshalb an NMDA-Antagonisten gearbeitet, die keine psychischen Wirkungen zeigen. Die Hamburger Biotechfirma Evotec beispielsweise, unterstützt vom Pharmariesen Roche, hat Anfang dieses Jahres mit einer klinischen Studie des Wirkstoffs „EVT 101“ begonnen, der nur die segensreichen, nicht aber die psychomimetischen Eigenschaften des Ketamins besitzen soll.

Doch was wäre, wenn genau diese unerwünschte Nebenwirkung den antidepressiven Effekt überhaupt erst hervorriefe?

Kennzeichen einer schweren Depression sind die tiefen Zweifel des Patienten, sich jemals wieder aus seiner Privathölle befreien zu können. Selbst erfahrene Therapeuten schaffen es kaum, jenen Grad an Freudlosigkeit nachzuvollziehen, der nicht wenige ihrer Klienten in den Suizid treibt – nicht aus Todessehnsucht, sondern nur, damit dieser unerträgliche Zustand endet.

Größere Studien sind auf dem Weg

Zur Entstehung von Depressionen gibt es viele Theorien. Eine davon besagt, dass sie die Folge von Verlusten und Ereignissen sind, die einen Menschen derart erschüttern können, dass sich seine Seele wie auf Eis legt. Ein als euphorisch empfundener Trip könnte einen schwerst Depressiven vielleicht aufrütteln aus seiner lähmenden Apathie. Eine existentielle Erfahrung, wie sie der Kanadier Bradley Weafer unfreiwillig machen musste, könnte schlagartig neuroplastische Veränderungen auslösen, die am Ende den Teufelskreis der Schwermut durchbrechen.

„Das drogeninduzierte Erlebnis und dessen Einbettung in den therapeutischen Prozess wären demnach der entscheidende Mechanismus, durch den sich eine Änderung im Gehirn und im Verhalten erzielen ließe“, schreibt der Züricher Psychopharmakologe Franz Vollenweider. Unverzichtbar sei dabei ein professioneller Rahmen, der den Patienten positiv einstimmt auf die bevorstehende psychedelische Sitzung.

Selbst unter solchen Voraussetzungen würde Carlos Zarate heute noch vom klinischen Einsatz abraten: „Wir müssen erst herausfinden, wie sicher und effektiv Ketamin wirklich ist. Wir brauchen größere Studien.“ Die sind inzwischen auf dem Weg.

Text: F.A.Z.
Bildmaterial: ASSOCIATED PRESS