'Brown Sugar' Junkies

A maverick doctor combines needle exchange and methadone to fight Iran's serious heroin problem. The Islamic government supports him - so far.

TEHRAN,

Iran -- In the unforgiving world of heroin addiction, 43-year-old Ali is a model of self-restraint. Anybody that is still alive after doing smack for 22 years -- an endless cycle of searching, scoring, shooting -- must know how to hold back a little.

"Most of my friends are already dead," he says during an interview inside the Persepolis Harm Reduction Center, off a back alley in a shabby part of Tehran. "But since I was working I didn't overdose."

Ali was no poster child for clean living, either. At the peak of his addiction he was pumping four-and-a-half to five grams of Afghani "brown sugar" heroin into his veins -- about a $20 a day habit -- a fortune in Iran, where the average income is only about $100 a month.

"I started stealing," says Ali. "I had to."

He couldn't make that kind of money in his job as a laborer, especially when he went to work high, which was nearly all of the time. And jail didn't deter him either. Ali says he's been arrested at least 15 times in the last 30 years. Iranian junkies say it's easier to score in prison than it is on the street. But the danger also increases; shared needles help to spread

HIV in Iranian jails like the common cold.

The drug addiction problem in Iran is more than a health care crisis. It is a broad societal one with staggering costs for communities and the government. Being neighbors with

Afghanistan, the world's leading producer of poppies (the source of opium and heroin),  doesn't help.

The Iranian government estimates there are at least two million people using drugs in a nation of 78 million. Of those, 200,000 are intravenous drug users and at least 50,000 are infected with HIV -- including Ali.

Ali's wife left him five years ago because of his habit. Then after more than two decades as a human pin cushion, shooting up everywhere he could find a vein that hadn't dried up like straw, the needle took its toll.

"My whole body became infected," he says, pulling up a pant leg to show a weepy wound that he says still won't heal after two years.

A year ago he decided to end the unforgiving relationship that had possessed him for so long. He says there were two reasons. He takes out his wallet from his back pocket, his fingers probe the inside and produce two small photos: His 11- and 13-year-old sons.

Ali, a heroin addict, describes his addiction, and a pioneering doctor discusses treatment.

Scenes from the drug clinic in Tehran.

"After my wife left, I realized there was no one to take care of my kids," Ali says, "so I had to do it."

Ali says the change from drug addict to recovering addict happened quite quickly, thanks to an innovative Iranian clinic, The Persepolis Harm Reduction Center. Unique to the Middle East, the clinic provides both needle exchange and methadone treatment under the same roof.

"One of the friends I would shoot up with told me about this place," Ali says, "so we came here to the clinic to get new needles."

While he brought in used needles for new ones, Ali says he noticed other addicts that were coming for methadone. They were well-groomed; their clothes were clean; they seemed much healthier than those still shooting up. Within ten days of coming to the clinic, Ali switched to methadone.

The fact that there is a needle exchange and methadone program for drug addicts in an ultra-conservative Islamic country like Iran is primarily due to the efforts of Dr. Bijan Nassirimanesh.

He is a pogo stick of a man, bouncing with frenetic energy, as driven to helping drug addicts as they are to their drugs.

"The list of why people start drugs is similar all over the world," he says. "It starts with curiosity and ends with pain. It can be everything from a kidney stone, to, as one client told me, the day he accidentally backed over his child with his car. The mind can't afford to tolerate this kind of suffering."

Nassirimanesh now has three Persepolis Harm Reduction Clinics in Tehran, all treating about 500 addicts a day. He says the number of addicts and the spiraling HIV figures scared the Iranian Ministry of Health enough to let him start a needle exchange (controversial even in the U.S.) and methadone program to combat the problem. It's a remarkable accomplishment in a country where many women still wear full-coverage, black "chadors" in public and where even talking about drugs and sex is strictly taboo.

And when Nassirimanesh opened his clinics he did something most other centers, even in western countries, rarely do: he put the needle exchange and the methadone programs under the same roof. He believes doing so helps the addicts, like Ali, in their evolution toward recovery.

"The guy on the methadone program comes into the center," he says, "and sees the guy on the needle exchange program all hunched over and dirty, probably hasn't bathed in weeks. It reinforces the idea that he doesn't want to go back to that. While the guy on the needle exchange looks at the guy taking methadone who is clean, maybe even has a job and he thinks, 'Why don't I try that?'"

But Nassirimanesh says while his clinic is a good model, he needs at least ten more in Tehran alone to even begin to have a real impact on addiction and the spread of HIV.

"You have to cover 80 percent of the people to be effective," he says. He blames "cold-turkey" drug centers and abstinence-based HIV programs for allowing addiction and disease to spread unabated. "Those places a have a bloody 10 percent success rate," he says, throwing up his hands in frustration. "What do you do with the other 90 percent?"

He says that much of international health care spending has strings attached that don't allow funding for clinics like his -- a mistake that he says is a death sentence for many.

Nassirimanesh says his energy and enthusiasm for attacking this crisis have made some question whether he isn't on drugs himself. But he says it's the suffering of others that motivates him; indeed, he lost half of his regular practice as a young doctor when he decided to make his first medical office double as a drop-in center for addicts as well.

He describes how he became transformed by the issues of life and death at an anatomy class during his second year of medical school.

"I saw the cadaver for the first time and I got up on a chair to get a better view," he says, actually getting up on a chair to demonstrate. "The body was perfectly preserved and I just stared to speak with him because he seemed alive. What is the meaning of human life, what is the meaning of death -- and I suffered from a minor schizophrenic stage. I closed off all sources of life, and I put pictures on a wall that represented questions to me: skeletons, a married woman -- after awhile I felt a transformation, I had some answers. When you pass this red line you are no longer a normal guy. My fears turned into an engine driving me."

He gives me a tour around the clinic, a three story building, on loan from the city. Nassirimanesh says though there's a lot of support for the clinic there's been talk of a possible eviction, something he's desperately trying to head off in talks with municipal and Ministry of Health officials.

The top two floors house administration and counselors as well as hundreds of boxes of syringes.

On the first floor is the drop-in center where addicts wait in line for methadone or to exchange needles. The walls are dingy and the place has no furniture, with the exception of a table for the doses of methadone, which is ground up with a mortar and pestle and placed in plastic cups. Space is at a premium here so in a cramped stairwell a bearded man in a white coat stirs a giant vat of bean soup, ladelling it out into disposable bowls for the men in line.

In another room Nassirimanesh shows me the kit given to addicts when they first join the needle exchange program. Aside from the cautionary guidebooks on HIV, it might seem like a heroin shooter's dream come true, with a collection of syringes, alcohol pads, foil for smoking opium, and a large metal spoon to cook heroin.

While we're touring the clinic a 28-year old man named Morteza comes in, looking for his methadone. He looks much better than a lot of the bedraggled clients coming into the center; he is sharply dressed and looks healthy, even fit, despite a heroin and opium habit that goes back seven years. He has been taking methadone for only three weeks, but already he says he feels like he's alive again.

He said he decided to quit his $12 a day habit because it was time.

"I just got tired of my life -- you don't know if it's night or day," he says. "I was just so exhausted. That's no way to live."

Things could have gone worse for him. He, like so many others, went into a life of crime to support his habit, holding up jewelry shops and banks with a toy gun. He was caught and spent two years in prison, but continued to get high there.

"Jail is the place for that kind of stuff," he says.

So far, he says, methadone is doing the trick for him.

"Methadone is a one-way valve," says Nassirimanesh. "Once you start using it it's hard to go back to heroin."

The reason, he says, is simple biology. The heroin high begins to peak before one hour and then drops fast. It puts the user into a drug-seeking cycle of injecting then searching for more.

And add to that, he says, the fact that the heroin rush only works for about six months of use. Then an addict has to use it just to reach a state of feeling normal. If an addict can't score, he starts to get sick.

Methadone's high is incremental, Nassirimanesh says. It puts the addict into a normal mood after about two or three months, without the roller coaster of chasing the drug. But methadone, he says, needs to be given for at least two to five years minimum -- sometimes a lifetime for long-term heroin users.

"And methadone is also cheap," he says. "An average addict here is probably on a $10 a day habit. We can treat them with methadone for about $10 a month."

Meanwhile, Ali, who survived 22 years as an addict, is now working here at the Persepolis Harm Reduction Center, the place he credits with saving his life.

Nassirimanesh hires many of his clients because "it's a way for them to become part of the solution instead of part of the problem. Plus, who knows better than a drug addict what works and what doesn't?"

"I wish someone had rescued me a long time ago," Ali says.  But at least he feels like he has his life back -- even though he bears the scars of his lifelong addiction, including an HIV infection.

Ultimately, he says his sons are proud of him and that's all that matters.

"They crawl all over me and kiss my face. I say don't, you might get HIV," Ali says. (Experts say HIV can only be transmitted through blood and bodily fluid exchange).

"'No, we don't care,' they tell me. 'We love you.'"

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