Heroin, a Doctors' Dilemma

By Claudia Wallis

Dear Committee:

Please do whatever you can to get heroin legalized for easing pain. As a nurse, I hear so many brave but torture-ridden people cry for relief from pain. So many patients just don't respond to morphine. Why must they scream and beg for relief?"

To Whom It May Concern:

My husband has been in constant pain with cancer of the lung, which has spread to the bones, the spinal column and the brain. Perhaps some of the people who are opposed to giving heroin should have to watch a person suffering day after day. I have watched my husband die by inches.

The letters pour into the Washington office of Judith Quattlebaum, 49. Again and again they tell a story that is all too familiar: the unremitting agony endured by a cancer patient, the frustrating sense of impotence felt by the family, and the apparent indifference of doctors seemingly more concerned about the latest advance in chemotherapy than about the comfort and dignity of their patient. Quattlebaum has been through it, having watched her grandmother slowly succumb to cancer. Seven years ago, she decided to act. Working out of her home, she organized the National Committee on the Treatment of Intractable Pain, now 6,000 members strong. Its mission: to win congressional approval for the use of heroin to relieve the pain of terminal-cancer patients.

Over the years, Quattlebaum's efforts have won considerable support in Congress, but several attempts to pass a heroin bill have been defeated. This year she is closer than ever. The Compassionate Pain Relief Act would authorize the use of heroin over a four-year evaluation period for hospitalized terminal cancer patients. It has been approved at the committee level in the House, and a companion bill has been introduced in the Senate. The bills have the support of such diverse political leaders as conservative Republican Barry Goldwater of Arizona and liberal Democrat Henry Waxman of California.

By and large, supporters have been persuaded by Quattlebaum's argument that heroin, which has been prohibited for use by U.S. doctors since 1956, is in many ways superior to morphine, the injectable narcotic most widely prescribed for cancer pain. According to Quattlebaum, heroin is faster acting because it is more soluble: "You can use half a cc of heroin, when you may have to use 20 times as much morphine." This is especially important in treating patients who are so emaciated that there is little muscle left in which to inject a drug, making a large shot extremely painful. Quattlebaum also suggests that heroin might prove helpful to those who are bothered by the side effects of morphine, which include night mares, nausea, constipation and hallucinations. Finally, Quattlebaum points to the experience in countries like Britain, where heroin is available as an analgesic. "Where doctors have a choice," she insists, "both patients and doctors prefer heroin."

But many authorities disagree with Quattlebaum's views.

The heroin bill is opposed by the American Medical Association, the American Hospital Association, the Reagan Administration and numerous medical experts on pain. One reason, and a factor in the past defeat of such legislation, is fear that medicinal heroin will find its way from the hospital to the street. But the larger question is whether patients will really benefit from the drug. "The evidence would suggest that her oin is the great non-issue of our day," says Kathleen Foley, chief of the pain service at the Memorial Sloan-Kettering Cancer Center in New York City. Foley, who has testified against the bill, challenges many of Quattlebaum's claims. While heroin is more soluble than morphine, she says, it is somewhat less potent than Dilaudid, a synthetic opiate already on the U.S. market. Nor is heroin likely to benefit patients who are allergic to morphine or are bothered by its side effects: new research by Cornell Pharmacologist Charles Inturrisi shows that once heroin enters the body, it is rapidly converted into morphine.

Perhaps most disturbing to many pain researchers is the prospect of large amounts of federal money going toward the preparation of heroin for medicinal use. "If the money and heat generated on the heroin bill were spent on developing new drugs and educating doctors on how to use the drugs we al ready have, patients would be a lot better off," insists Dr. Michael Levy, director of palliative care at the Fox Chase Cancer Center in Philadelphia. This view is shared by Dame Cicely Saunders, the English founder of the hospice movement, which popularized the use of heroin in Britain to relieve dying patients. The controversy over heroin, she says, is focusing attention away from the main issue, which is "the need to improve the general standard of care." In particular, she says, there is a need to ensure that a misplaced concern about addiction does not prevent doctors from prescribing large enough doses of opiates to relieve patients with advanced cancer.

Despite these arguments, some members of the medical community believe that heroin deserves the four-year trial proposed in the bill even if it helps only a handful of people.

"We don't know if one patient in 10,000 will benefit," says Pharmacologist William Beaver, of Georgetown University, "but we ought to find out."

-- By Claudia Wallis. Reported by Patricia Delaney/Washington ami Ruth Mehrtens Calvin/ New York

With reporting by Patricia Delaney, Ruth Mehrtens Galvin