The official U.S. response to the free heroin trial about to begin in Vancouver is predictably negative. A spokesman for John Walters, director of the White House Office of National Drug Control Policy, calls it “an inhumane medical experiment.”

“I would bet any amount of money the U.S. has exerted extreme pressure on Canada to abort this trial,” Alex Wodak, a prominent Australian addictions researcher, has said. He should know: U.S. opposition helped to abort a heroin trial in his country. It is to Ottawa’s credit that Canada has resisted similar pressure from the Bush administration, whose addictions policies owe more to narrow moralism than to science, compassion or insight.

And Canada must withstand more U.S. displeasure if the results of the Vancouver experiment point to our introducing heroin by prescription as part of our addictions treatment armamentarium.

The Vancouver trial, known as the NAOMI project (North American Opiate Medications Initiative), will compare the risks and benefits of heroin with those of the synthetic opiate methadone. Similar studies in Switzerland and the Netherlands showed reduced criminal activity, increased employability, a better likelihood of remaining in treatment — and, in some cases, of quitting narcotic use altogether.

I’m a physician working with an addict population in Vancouver’s Downtown Eastside, just half a block from the NAOMI site. I don’t expect glowing outcomes in terms of addicts becoming employable or abstinent. Most of the clients in our area are too demoralized, too dependent on other drugs such as cocaine and, above all, too lacking in resources to make such radical changes. What is realistic is to look forward to less crime, better health measures such as reduced hospitalization rates, and closer compliance with treatment. Even such modest goals, if achieved, would be a vast improvement in the lot of many hard-core drug addicts.

It would be simpler if the naive U.S. view were accurate, and addicts could be induced or educated into achieving abstinence, if — like the highway signs erected by the Reagan administration—people could “just say no.” It isn’t like that. The men and women I work with have had every possible negative consequence visited on them. They’ve lost their jobs, their homes, their spouses, their children and their teeth; they’ve been jailed and beaten; they’ve suffered HIV infection and hepatitis and infections of the heart valves and multiple pneumonias and abscesses and sores of every sort. They will not, until something spontaneously transforms their perspective on life, abandon their compulsion to use drugs. The question is only this: How shall we, as a society, respond to their predicament? With unenforceable laws? With moral preaching? With medical practices that don’t embrace the full range of options?

Abstinence is a realistic goal for some drug addicts, but, among the downtown hard core, only an infinitesimal few. Rehabilitation offers hope for many more, but, among my patients, that’s still only a minority. In part, that is due to their being mired in addictive cycles and, in part, due to the sheer lack of adequate facilities, halfway homes and well-trained staff. This society lacks the political vision and will to establish and fund the wide-ranging, gradual, step-wise programs most addicts need to escape their habits.

What remains is the harm-reduction model. It’s designed not to change anyone but to reduce the noxious effects of abusive childhoods, personal dysfunction, irrational drug laws, social neglect and a lifetime of bad choices. For some, only the provision of prescribed heroin can break the cycle of crime and life in the streets.

This week, I visited one of my patients, hospitalized with abscesses throughout his body and bacterial invasion of his bloodstream. This man once lay down on a railway track, in a drug haze, and woke with a shattered hip and an amputated arm. I asked him why all this wasn’t enough to make him give up drugs. “I spend my whole day,” he said, “begging and scrimping and lying for 40 bucks to get a hit. And that gives me relief from pain for maybe five or 10 minutes and it gives me a freedom I can’t describe. And that five minutes is worth it.” I debated with him the merits of such “freedom.” But as a doctor, I can try to reduce his suffering. That, regardless of what winds blow from Washington, is what the NAOMI project is about.