How the HIV/AIDS epidemic has had an unexpected side effect.
By John Ainger
"Where are you from?" I asked.
"Iraq. Kurdistan!" he said, animatedly jabbing with his index finger at the Kurdish flag tattooed upon his gaunt neck. He then engaged in a bit of light-hearted banter, "This guy, this guy is the proper junkie," Hajji laughed, gesticulating to Morten, the man I was talking to. "He calls me the junkie, the garbage man," Morten explains to me, "But he’s not bad for a black guy," he quips whilst wrapping Hajji in a loose and stumbling headlock.
This brief moment of lively animation took me by surprise. I had been talking to Morten, though trying unsuccessfully to get more than monosyllables from him. I would ask a question, Morten would then pause, as if he was about to answer, before placing all of his very limited concentration into how he was going to tie his 'new', yet chipped, skateboard onto his rucksack so he wouldn’t have to hold it. Morten explained that he’d managed to get the skateboard… from a girl… but where she worked? He tailed off…
Years of heroin abuse have taken their toll on both Morten and Hajji. Apart from the inability to really hold a conversation, both have all the telltale signs of addiction. Both are slight in stature and are 'gouching' - lethargy symptomatic of having recently injected smack. Hajji is missing several teeth and both limp across the ground as if with serious leg and hip ailments. These physical manifestations are not the only ways Morten and Hajji are typical of the modern heroin addict.
Heroin users are not used to being in the spotlight, indeed they try and shy away from it. Never has this been more evident than today. Aside from the odd celebrity death and moral panic surrounding a skinny model, the newspaper and website headlines are dominated by stories surrounding the legalisation of cannabis, skunk, and the increased use of legal highs by Western Europe’s youth. The fact is heroin is not in vogue- not with the media and not with young people. This has two very important implications however: 1) The film 'Trainspotting' is out of date; and 2) Today’s heroin users are getting old.
Morten is 36, Hajji is 40.
Just like the Bunsen burner, the coffee filter, the pretzel, the Easter Bunny and the Kindergarten - heroin was a German invention. It was invented by the same company who invented the aspirin, Bayer, in 1898. Initially, it was very popular due to its fast-acting pain relief and was prescribed by many doctors ahead of morphine.
Small heroin subcultures later emerged within the social experimentation of youth culture in the 1960s and 1970s along with cannabis and LSD. By the mid-1970s, the use of heroin had become prevalent in the drug scene, particularly in the cities, as the drug supply increased. Myanmar was the old Afghanistan. This uptake in heroin use coincided with the 'baby-boom' generation. Young people in Western and central Europe made up around 96 million in 1990, compared with fewer than 80 million today.
The impact of heroin punches far above its weight on a societal level, when compared with the relatively small numbers of people who take the drug. For the individual, heroin use is associated with chronic health issues, such as cardiovascular and lung problems, while long-term users also suffer from chronic pain. In addition, users frequently put themselves at risk of infection from diseases as serious as HIV/AIDS and Hepatitis C; the latter can cause cirrhosis of the liver.
Juliana Ashworth worked at the Equinox care centre in Brighton for 10 years, between 1993 and 2004. According to her, heroin users rarely just take heroin, but 'multi use', "Drinkers don’t dabble in the heroin," she says, "but heroin users dabble in the booze." But it can often be more serious as certain drugs combined can make for disastrous consequences. Juliana states that many of the clients at the Equinox centre died when coupling heroin with a benzodiazepine, such as diazepam, in an effort to counter the effects of withdrawal. Their respiratory systems would cease to work and simply, they would stop breathing.
Heroin users do not just die from overdoses alone. A Swedish study in 2010 surveyed the deaths of 210 opioid (a group of drugs of which heroin is the most common) users. It stated that 20% of opioid deaths were caused by cardiovascular diseases, 15% suicides, 15% accidents, 12% tumours and 12% liver cirrhosis.
The societal effects however, arguably outweigh the direct impacts of heroin addiction. "The thing that struck me most about the heroin users as opposed to the drinkers, which really scared me about what heroin does to you, is it completely zaps your emotion," Juliana recounts, "One couple went on holiday to Morrocco and sold their 3 year old boy for money to buy more drugs. It was all about the goal of heroin."
Families are often torn apart by the addiction, while the mental health of a long-term addict is also deeply impaired, "It’s a chicken and egg scenario," Juliana says, "You don’t know whether the mental health problems came before or after the drug abuse." Furthermore, hotspots of heroin addiction correlate with high crime rates surrounding the habit; the network of dealers and gang crime, not to mention the riskier behaviours undertaken by chaotic individuals seeking to get their fix. So far a familiar story…
Recent research suggests that rates of heroin addiction are falling across Western Europe, a phenomena that can be attributed to the lack of young people taking up the drug. In 2007, 59,000 heroin clients entered treatment for the first time whereas in 2013, the number was less than half, at 23,000. The lack of young people taking up the drug has ironically left an ageing heroin population; a population that poses a number of problems for treatment centres across Western Europe.
While old-age in Europe is generally considered anything over the age of 65, what is considered old-age for drug users is, unsurprisingly, far lower. Most studies use age 40 as the cut-off but some go as low as 35. Within the realm of heroin addiction, the largest killer, a long-term addict is often lucky to reach such an age. However, according to the latest edition of the European Drug Report, which comes out annually, the average age of opioid use increased by five years between the years 2006-13, while the average age of drug-induced death (mainly related to opioids) increased from 33 to 37.
This statistic is echoed by the experience of Morten Aagaard, the leader of Kirkens Korshaer (the Church Army) in Aarhus, Denmark: The centre frequented by Morten and Hajji. Morten is a tall, well set man-ironically the opposite of many of his guests. Although he has white hair, he is hard to age, as his eyes peer at me through his wide-brimmed spectacles. "I have this saying that I took 10 years for the holy people of Copenhagen, 10 years for the rich people of Billund and now 10 years for the poor in Aarhus," he jokes, "We get all sorts of funny people here," he says in a completely un-patronising manner. Kirkens Korshaer is placed right in the heart of Aarhus, though you would not know it was there. "The residents don’t mind at all," he says, when I ask how people feel about a drug centre in the middle of this bustling city. The centre provides Christian shelter to 250 heroin addicts, 170 of whom are 'active' and attend regularly. Morten nods violently when I ask whether the age of addicts is increasing. Most of them are aged between 30-40, "but all will eventually die," he says matter-of-factly. I assume their deaths will be drug related, rather than due old age.
The majority of 'old' drug users are intuitively located within Europe’s major cities as these are more often than not where drug trends start and drugs are easier to sniff out. For example, Amsterdam houses 90% of The Netherlands’ ageing heroin addicts, while 36.6% of Paris’ addicts are over 40 compared to just 7.8% in Lille. Likewise, the heroin epidemic in Denmark started in Copenhagen before spreading out, explaining their high proportion of older addicts.
Part of the reason for this trend is of course, the overall ageing population across much of Western Europe. Scholars and mainstream media have labelled this the 'baby-bust' following on from the 'baby-boom' after the Second World War. Fertility rates have fallen across much of Europe with the average couple having just 1.5 children today (well below the replacement rate of 2.1) compared with 2.7 children in 1960. This has led to a near doubling of the proportion of people over the age of 60, from 8% to 15%, as well as a significant increase in the average age. This accounts for some of the rise, as heroin abuse is often a chronic addiction and long-term users find it nigh on impossible to give up. However, this explanation alone does not fill the whole 1-gram bag.
To highlight the point, the US’ fertility rates have also been declining over a number of years, if not quite to the same extent as Western Europe’s. It currently is also below the replacement rate. Yet the US is suffering from what The Economist described as 'The Great American Relapse,' as the number of heroin users has almost doubled from 370,000 in 2007 to 680,000 in 2013. Unlike Europe where the youth are turning to different drugs - cannabinoids in mainland Europe and legal highs in the UK - heroin use has increased among the young, affluent and white population in the US. But these statistics also mask a significant development when comparing the US to Europe. Europe’s heroin population is living much longer, a trend that would not be seen if purely demographics and new drugs were cited as the reason.
Drug abuse, particularly that of heroin, and the policies that are needed to effectively combat its corrosive effect is an incredibly complex task. Since the hippy wave of peace, love and happiness, governments have attempted to curb drug use by attempting to control the supply. While heroin use has diminished in Western Europe, the supply has not followed suit. The invasion of Afghanistan created a literal fertile field in which to grow poppy plants, the dried latex of which is used to create opium and is then converted into heroin. Heroin is less bulky than its predecessor and therefore can easily be transported. It is currently estimated that Afghanistan, like Myanmar before it, produces 90% of the brown heroin found in European cities. Incredibly this percentage is increasing, opium production went up 7% last year.
The continued instability in the Middle East is likely only to increase the supply of heroin to European markets. Upheaval in Iraq and Syria as well as a thawing relationship between Turkey and the West is likely to open up the 'Balkan Route' into Eastern and Central Europe. Furthermore, the 'Southern Route' through Northern Africa is equally in turmoil as highlighted by the recent migrant crisis. According to the European Drug Report, the southern route has gained importance in recent years. The report also highlights the recent innovation in supply networks that has taken place.
This said, there has been no real decrease in price, but there has been no increase either. Addicts at the Kirkens Korshaer centre in Aarhus stated that there had been no change in the price but the purity has gone up. This could perhaps be attributed to the discovery of a number of domestic heroin refineries in Europe itself.
Irrelevant of whether the supply has gone up or simply remained stable, efforts to control the supply have largely failed. And while the supply of heroin does not affect the numbers of young people taking up the drug, it fuels the chronic addiction of the older generation of addicts. Unlike with some drugs, users do not 'grow out' of heroin addiction.
When I asked Morten, now 36, when he took up the drug he laughed, "Not soon enough!" before sadly whispering, "That’s a lie." Morten started at age 20, which he has been told was actually quite late for the time. Before heroin he took amphetamines. Few people start at that age now, but the ones who did and are still shooting up into their 30s have little hope of giving up. After years of abuse, the brain changes significantly. The best they can hope for is substituting the drug with an alternative such as methadone or Suboxone for as long as it take for their brain to repair. Morten Aagaard, the head of the centre, is resigned to the fact that, "Only one out of a hundred will quit," once they become a long-term abuser.
The increased supply does not explain however, why heroin addicts are getting older. It merely explains how they are able to still get hold of the product that, over the years, they have become so attached to. In order to come up with an explanation, we have to go back to the developments in Europe during 1980s and 1990s.
1980s Europe was gripped by an HIV/AIDS epidemic and the response to this quickly moving disease was slow. The first HIV treatment in Europe was not approved until the late 1980s by which time the numbers of newly diagnosed HIV cases in Europe had increased 21-fold from 5000 in 1985 to 112,000 in 1991. Over the same time period, the number of deaths from the disease had increased staggeringly 45-fold, from 900 to 39,000. Importantly, this trend coincided with another epidemic: the increased use of heroin within Europe’s borders.
The need to stop the spread of HIV/AIDS drove Europe’s drug policy, resulting in improved conditions for heroin addicts as a by-product. The first government approved needle-exchange programme had been implemented in the Netherlands by the mid-1980s, signalling a revolution on the continent in how drug users were treated. Around the same time, drug consumption rooms, or ‘fix-rooms’, sprang up starting with Berne, Switzerland, in 1986. These simultaneously provided users a safe and hygienic place in which to inject heroin, as well as dramatically slowing the spread of HIV/AIDS.
Denmark is also a world leader in the provision of 'fix-rooms'. Kirkens Korshaer opened theirs at the end of 2013 after government legislation stating that any municipality could open one. Users can inject heroin or smoke crack in a heavily ventilated room, "Only the people who smoke and the pigeons get high!" he chortles. But these rooms, originally set up to halt the spread of viral disease, have had a surprising side-effect: heroin users no longer die. "Nobody dies," states Morten as he recounts a story of a man who overdosed in front of him after leaving prison. "I just pushed air back into him and called the ambulance," he said, as I responded with a shocked look on my face.
These fix-rooms are perhaps a symptom of a larger attitudinal shift across the continent when it comes to drugs and drug abuse. Nowhere is this better exemplified than by Morten Aagaard and Kirkens Korshaer. Kirkens Korshaer is a Christian organisation and Morten himself is an avid follower. I was surprised when I heard of his pragmatic approach, "I don’t agree with taking drugs but people have the right. Just like I don’t agree with abortions and suicides but people have the right," he says. It takes me by surprise, as I am normally familiar with religious organisations advocating abstinence, not the opportunity to take heroin freely or substitute it for methadone. For example, it is easy to find horror stories about the failings of the 12-step programme in the US when it comes to opioid abuse.
This is not to say that all countries have the same levels of legislation. While Portugal decriminalised the possession of small amounts of recreational drugs, including heroin, the levels of freedom vary across the continent. In some places it is still not seen as a disease, but a crime. The UK for example has no drug consumption rooms, despite calls for one in Brighton, Juliana Ashworth’s hometown. The vice-chairman of the city’s independent drugs commission simply said, "The time is not right."
As heroin users get older and treatments adapt, it is ironically the youth whom Morten finds it difficult to accommodate, "We have nurses and counsellors for the older addicts," he says, "but the young need Mums and Dads to give them a kiss and a cuddle." The centre provides opportunity for self-improvement, the chance to make oneself look and feel better despite the toll of drugs. But parenthood is the one thing it cannot provide. "I would take the young ones home if I could," but understandably this is one step even Morten is unable to go to.
Despite heroin addicts living longer, the outlook is not bright. When you have been taking a substance such as heroin for over 20 years it becomes a bitter friend, the end rather than the means. Morten and Hajji have little idea the role AIDS played in increasing their life-expectancy but they probably wouldn’t care. I leave them, with Morten scrabbling round in his pocket for something. He has withdrawn into himself once more. He pulls out a single coin. They sell cigarettes over the counter here. He buys two, one for himself and one for his partner in crime, Hajji. I wonder if he would be that generous when it comes to the darker substance.