On November 29, the first of several disoriented, apparently drowsy people wandered into Bay Area county hospitals with slurred speech, drooping eyelids, and difficulty swallowing. By December 2, at least three patients were paralyzed above the waist and required mechanical ventilation.
The mysterious, rapidly progressing illness turned out to be wound botulism — a rare disease caused by a toxin in C. botulinum bacteria. Alameda and San Francisco county public health officials immediately notified the California Department of Health Services of the outbreak, which later alerted the federal Centers for Disease Control and Prevention.
Like most recent victims of wound botulism, these six patients have one characteristic in common: They are all black-tar heroin users who contracted the toxin-releasing bacteria from a dirty drug batch.
Botulism cases always raise alarm because C. botulinum is not only a bioterrorism agent but a particularly nasty bug. Exposed victims experience rapid descending paralysis, or gradual loss of muscle control beginning with the smaller muscles in the head and moving downward.
By the time three of the six patients — one of whom is an Alameda County resident — made it to San Francisco General Hospital, they were in critical condition. In the coming weeks — or even months — they will need around-the-clock intensive care while an antitoxin slowly unbinds neurotoxin from their muscles. All told, the outbreak could cost taxpayers hundreds of thousands of dollars.
Wound botulism is a primarily Californian disease. The state has 75 percent of the cases in the United States, which in turn has 90 percent of the cases reported across the globe. The illness was virtually unheard of prior to 1988, but since then California has seen a twenty-fold increase in infections. Experts at the California Department of Health Services believe the recent surge in cases can be explained by two related developments in the heroin-using community: the increase in popularity of black-tar heroin from Mexico, and the practice of “skin popping,” or injecting heroin into soft tissue rather than veins. Repeated injections cause abscesses to form, creating a favorable climate for neurotoxin-producing bacteria like C. botulinum.
Last month’s deluge of botulism infections likely represents only a fraction of the cases that the state’s hospitals can expect to see in 2005. On average, 22 cases emerge each year and cost an estimated $4.5 million in health-care expenses. Public health officials would like to find a way to stem the trend, but because heroin users are hard to reach and because their habit is illegal, prevention efforts have been largely ineffectual.
“Not using isn’t always a reasonable option to these individuals, and once they have wound botulism, you can’t do much about it,” says Dr. Erica Pan, head of San Francisco’s Bioterrorism and Infectious Disease Emergencies Unit. “It’s frustrating from a public health perspective.”
Yet there is evidence that one approach could drastically cut wound botulism cases and a host of other negative effects associated with heroin use, including crime, homelessness, and HIV and hepatitis C infection: Controlling addicts’ heroin supply. Under this strategy, public agencies would buy “clean” heroin and offer it to addicts in regulated, prescribed doses so they don’t have to rely on an unsafe street product.
While many people are uneasy about the prospect of local government getting into the business of dispensing heroin, there is growing support for the idea — especially abroad. The Netherlands and Switzerland have already tested prescription-heroin treatment programs and seen impressive results. A five-year study of Switzerland’s program — which has existed since 1992 — found crime had dropped by 60 percent and unemployment by 50 percent. Significant public funds were saved thanks to a reduction in legal costs, imprisonment, and disease treatment after the program commenced.
This remarkable success inspired Canada to fund its own prescription-heroin pilot study, which will begin early next year. But here in the United States, support for the idea has been tepid at best. Critics of the approach — including drug czar John Walters — say it encourages drug dependence and robs addicts of the opportunity to kick their habit.
Ideology aside, the Swiss and Dutch experiments do show that it’s simply more cost-effective to regulate heroin use than to punish it. “The cost of providing heroin treatment is truly pennies on the dollar compared to the alternative,” says Daniel Abrahamson, the Oakland-based director of legal affairs for the Drug Policy Alliance. More important, he argues, prescription-heroin programs help intractable addicts return to normal, productive lives and, in some cases, to eventually give up the drug altogether.
“When you prescribe pure, known levels of heroin to individuals, you enable them to not spend every waking moment of their life figuring out how to get their next hit — it frees up time to figure out how to get well,” he says.
That currently isn’t an option for the six patients who contracted wound botulism last month. As they recover in the coming weeks, they will be discharged and, as statistics overwhelmingly suggest, will likely return to their old habits. They may even contract wound botulism a second or third time, as some addicts have in the past.
“The question is really: ‘This problem exists, so what do you do?'” Abrahamson argues. “One option is to look at the very strong medical and scientific research that heroin maintenance reduces disease, crime, and the suffering of addictive people.”
