Chapter 5
Recovering from Heroin Addiction

Before the 1960s, the only form of treatment available in the United States for heroin addiction was imprisonment in a federal correctional facility. Since there did not yet exist recovery programs to help end the cycle of heroin addiction, the only resource available to these addicts upon their release from prison was the support of their parole officers. Predictably, these addicts quickly returned to heroin use and its associated behaviors.

In recent decades, however, medical science has come to understand heroin addiction as a complex but treatable physical and mental illness, rather than a crime. Experts now know that with the proper treatment, people can and do recover from heroin addiction. They also understand quite well, however, that the recovery process is long and difficult.

Deciding to Recover

Most heroin addicts who have entered recovery programs found the resolve to do so only after having "hit bottom." An addict is said to have hit bottom when he or she arrives at the decision that life has grown unbearable because of drug addiction. Addicts can hit bottom due to any combination of the many physical and emotional consequences of heroin addiction, and the depth to which an addict must sink before hitting bottom varies widely from one individual to the next. The less time it takes for an addict to hit bottom, the better the chances for recovering—not only because the consequences of heroin use will be minimized, but also because heroin addiction is considered a progressive illness, which means that the longer one remains addicted, the harder recovery becomes.

Substance abuse counselors sometimes use a technique called intervention to attempt to convince the addict to enter recovery before hitting bottom. The counselor, along with the addict's family, friends, and even coworkers, meet with the addict. In a loving and supportive way, the group asks the addict to honestly assess the negative effects of his or her addiction. If the addict consents to entering recovery, the counselor makes the necessary arrangements. Very often, however, the addict feels attacked and betrayed by intervention efforts, which are effective only a small percentage of the time.

Free Heroin Clinics

During the years preceding the time when heroin was made illegal in the United States in 1924, in an effort to curtail heroin addiction, public health officials took the controversial step of opening forty clinics across the United States where addicts could go to obtain free heroin. The doctors who operated the clinics suggested that they improved addicts' health, since one condition for receiving the free drug was that addicts had to undergo medical examinations and treatment. Critics note, however, that many people tried heroin for the first time at these clinics, and that the program inadvertently raised the number of addicts in the country.

In 1998, the World Health Organization (WHO) conducted clinical trials in Geneva, Switzerland, to determine whether the practice of providing heroin to addicts in a clinical environment was a useful solution for the problem of addicts who refused methadone. The initial findings of the WHO committee suggested that free heroin clinics provided a number of benefits to society, including reduced crime, and heightened public interest and awareness on the issue of heroin addiction. Further benefits, they suggested, lay in the program's requirements that addicts forfeit their driver's licenses and receive frequent health screenings as a condition for participation in the program. These conditions, they found, protected the safety and health of the general public, and saved millions of dollars in medical expenses. Based on these findings, research facilities in the United States, including Johns Hopkins University, began to investigate the possibility of conducting similar clinical trials.

Though heroin addicts arrive at the decision to enter recovery under a variety of circumstances and for a variety of reasons, they must all begin the recovery process with a common first step, which is detoxification from the drug. The experience of detoxification is one with which all heroin addicts are already familiar to some extent, since they experience the beginnings of it every time the effects of the drug wear off and withdrawal symptoms begin to occur. When addicts undergo detoxification without the aid of medications to ease their discomfort—an experience addicts often refer to as "going cold turkey"—withdrawal symptoms reach peak severity about twenty-four hours following termination of drug use, and can continue at this level for up to a week or more. Though intensely unpleasant, unless severe health problems already exist, the detoxification process is not ordinarily life threatening.

To avoid the withdrawal symptoms that accompany detoxification, addicts entering recovery may elect to take medication to either prevent these symptoms or lessen their severity. The most commonly used drug for this purpose is methadone. Methadone, which is administered orally and given in decreasing doses over a seven-to tenday period, can provide a relatively symptom-free detoxification. A drawback of using methadone for detoxification is the fact that methadone itself is addictive, and causes withdrawal symptoms of its own when the addict discontinues its use. Its symptoms are milder than those of heroin, however, and can themselves be lessened with other medications.

Other medications used to ease heroin withdrawal are nonaddictive. Clonidine, for example, which was originally a blood pressure medication, has been found to be a helpful alternative to methadone for those who do not wish to create a new drug dependence. While not as effective as methadone in suppressing muscle and joint aches, clonidine does provide significant relief for the anxiety, chills, running nose, and stomach cramps of withdrawal. Withdrawal symptoms can also be treated individually as needed with over-the-counter remedies such as ibuprofen.

Inpatient Treatment Programs

Many addicts may undergo detoxification on an outpatient basis, living at home but reporting to a hospital, drug clinic, or doctor's office daily to receive both withdrawal medication and counseling. Most substance abuse counselors believe, however, that it is preferable to undergo detoxification in an inpatient treatment program, in which addicts live for a prolonged period of time in an addiction treatment facility and undergo withdrawal under constant professional supervision. One obvious benefit of detoxifying in an inpatient facility is that the addict does not have access to heroin. Another benefit is the fact that the addict receives the constant support and encouragement of counselors, most of whom are recovering addicts themselves, and is surrounded by other detoxifying addicts who are also embarking on the long journey to recovery.

Most inpatient facilities use the "therapeutic community" approach, which combines the cold turkey approach with group therapy and support from other recovering addicts. "This is chemical cold turkey," note the directors of the Haight Ashbury Free Clinic in San Francisco, "but the community usually maintains a high level of support to counter withdrawal and to create a healing atmosphere for aftercare and recovery."³⁷ Life in a therapeutic community also usually includes daily participation in group therapy sessions, in which addicts voice and examine their feelings with the help of fellow addicts. Some therapeutic communities cater to specific groups of heroin addicts. For example, there are programs that allow women to live with their children, to help them learn responsible parenting skills. Many facilities also prepare addicts for employment, and provide other skills that are helpful for reentry into society.

Successfully completing detoxification, even in a rigorous inpatient program, is merely the first step involved in recovery, however, and it offers no guarantee that the addict will remain clean. "Heroin addicts" states the New York Times, "are notoriously resistant to permanent recovery. More than 80 percent of addicts who manage to withdraw from heroin eventually go back to it."³⁸ Though the addict's physical dependency on the drug may have been broken, mental and emotional dependency can still be severe indeed, and can cause repeated relapses.

Treating heroin addiction, explains author Margaret O. Hyde, "can be as demanding of patience as the curing of cancer."³⁹ Regardless of the time period in which an addict has abstained from using heroin, tolerance never returns back to zero, and it reaches high levels far more quickly in a relapsing addict than it does in beginning heroin users. Thus, the relapsing addict soon needs large amounts of the drug to stay high.

In recent years, Academy Award–winning actor Robert Downey Jr. has demonstrated for the American public how overwhelming the temptation of heroin can be for a recovering addict—even for one who has completed numerous inpatient treatment programs, as well as jail sentences, for drug use. "It's like I have a loaded gun in my mouth and my finger's on the trigger," Downey told a judge during a court appearance for drug charges in 1999. "And I like the taste of the gunmetal."⁴⁰

The kind of overwhelming cravings experienced by recovering heroin addicts seem to be quite different from those experienced by addicts of other drugs. Referred to as "junk hunger," these cravings are often described by addicts as a strong feeling of sadness combined with a physical sensation of emptiness within the abdomen. Though researchers know that junk hunger is the result of one or more of the various permanent chemical and physical changes that take place within the heroin addict's brain and body, they do not yet know the exact cause of junk hunger. Nor do they know why some recovering addicts experience it to a far greater degree than others. The Do It Now Foundation explains that whatever its cause, "learning to handle recurrent flashes of junk-hunger is something that a good many ex-junkies get to handle for the rest of their lives. But considering the alternative, most think it's not a bad trade-off."⁴¹

Acupuncture

Acupuncture, which has been used by physicians for thousands of years in the Far East, is gaining widespread acceptance in the West for the treatment of heroin addiction. Based on the ancient Chinese therapeutic practice of inserting very fine needles in key nerve centers, acupuncture treatment for heroin addicts was pioneered by Dr. Michael Smith at New York City's Lincoln Hospital in 1972, where he found that it provides heroin addicts with significant relief from the symptoms of withdrawal, as well as the "junk hunger" that can make long-term recovery difficult. Daily acupuncture sessions have since been shown to lower the dropout rates in detox centers significantly. Though researchers do not yet understand how acupuncture achieves these results, they suspect that the needles stimulate the brain's production of endorphins and other neurotransmitters.

Lifelong Methadone Maintenance

For hundreds of thousands of addicts who wish to recover but are unable to withstand the craving for heroin, help is available through methadone maintenance programs. In addition to preventing withdrawal symptoms during an addict's detoxification, daily oral doses of methadone can also provide ongoing relief for the addict's heroin cravings without creating any intoxicating effects, and without the need for increases in dosage. Also, methadone actually blocks the effects of heroin, so that the addict will not get high if he or she does take the drug. So long as the treatment schedule is followed, a methadone maintenance patient will be a normally functioning, alert, and healthy person. A thirty-seven-year-old housewife in Brooklyn, for example, says this of her experience with methadone maintenance:

I began using drugs when I was twelve. By the time I was sixteen I was shooting heroin, living in the street, really down and out. I've been on methadone since I was twenty, and it's kept me on the road. If it hadn't been for the program I'd be dead. Now I'm on the board of the PTA at my daughter's elementary school. I go shopping, take care of the house, love my family—my life looks as normal as anyone else's. No one knows I'm on methadone, not even my daughter.⁴²

Among the benefits to society of methadone maintenance programs is a steep reduction in the crime rate among the addict community, as well as a slowing of the spread of AIDS and other communicable diseases because of the reduced number of intravenous heroin users. Despite these significant benefits to individuals as well as to society, however, some recovery experts object to the practice, suggesting that heroin addicts can and must achieve sobriety without the aid of medications to fully recover from their addiction.

While the topic of methadone maintenance is hotly disputed, there is widespread agreement in the recovery community that there is a significant difference between simply living clean and actually recovering from the emotional damages of heroin addiction. "Many heroin addicts," explains Margaret O. Hyde, "have . . . emotional problems or character disorders before they become addicts. Even if they do not, their life develops into one in which they lie, cheat, and steal in order to get the drugs that they need."⁴³ Thus, many addicts struggle with painful feelings such as guilt, shame, and inferiority upon getting clean. Making matters worse, addicts usually come out of addiction at about the same stage of emotional development at which they entered it. Even valuable insights and positive attitudes learned during extended inpatient treatment programs can fade from memory with the passing of time, leaving the addict at the mercy of despair, and therefore in danger of returning to drug use.

Support Groups for Addicts

In an effort to keep from returning to heroin use, as well as to recover emotionally from heroin addiction, many recovering addicts join support groups. The largest by far of these groups, Narcotics Anonymous (NA), is modeled after the highly successful alcoholic support group, Alcoholics Anonymous. NA and similar support groups call themselves "twelve-step" groups because they employ the Twelve Step Program of Recovery used by Alcoholics Anonymous. This program's twelve steps outline the actions that addicts need to take to recover from addiction.

One of the many ways that the twelve steps help addicts to recover is by requiring them to acknowledge to themselves and another person all of the people that they harmed on account of their addiction, and to then set about making amends with those people if possible. Many addicts find that this step eases their conscience tremendously and therefore makes the idea of remaining clean seem less daunting. Another emotional need is met by a step that requires the addict to attempt to help other addicts in their recovery process. In addition to curtailing the self-centeredness that is so characteristic of addicts, this step provides the addict with a new sense of purpose in life, and a meaningful alternative to being high. "The idea of one addict helping another," notes Anthony Kiedis of this effective aspect

The Twelve Steps of Narcotics Anonymous

The following are the 12 Steps of Narcotics Anonymous. These steps, which were adapted from the 12 steps of Alcoholics Anonymous, summarize Narcotics Anonymous's program of recovery from addiction.

1. We admitted that we were powerless over our addiction, that our lives had become unmanageable.
2. We came to believe that a Power greater than ourselves could restore us to sanity.
3. We made a decision to turn our will and our lives over to the care of God as we understood Him.
4. We made a searching and fearless moral inventory of ourselves.
5. We admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. We were entirely ready to have God remove all these defects of character.
7. We humbly asked Him to remove our shortcomings.
8. We made a list of all persons we had harmed, and became willing to make amends to them all.
9. We made direct amends to such people wherever possible, except when to do so would injure them or others.
10. We continued to take personal inventory and when we were wrong promptly admitted it.
11. We sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as a result of these steps, we tried to carry this message to addicts, and to practice these principles in all our affairs.

of twelve-step recovery, "there is nothing that touches that as far as I'm concerned."⁴⁴

Also common to most twelve-step programs is a spiritual element—a belief that addicts must rely on their individual understanding of God for the strength and wisdom to remain clean. Although not every recovering addict believes in God, the directors of the Haight Ashbury Free Clinic in San Francisco suggest that the twelve-step approach can work for any addict, regardless of his or her views on religion:

In truth, there are many chapters of AA and other self-help programs that do have a decided religious bent. On the basis of this and the many references to God and prayer in the twelve steps, some people have accused the self-help movement as a whole of being in some way related to the fundamentalist Christian movement. It is not. But those who cannot accept these aspects of a program should not categorically reject all self-help groups. There are meetings of self-help programs for agnostics, atheists and even secular humanists. These programs will definitely take a different interpretation of "God as we understood Him," which is fine.⁴⁵

In addition to twelve-step and other kinds of secular addict support groups, other chapters of these organizations target specific groups of addicts, such as those infected with the HIV virus. Thus, while it is doubtlessly true that no particular support group suits all addicts, the wide variety of recovery support groups available makes it extremely likely that any recovering addict can find a suitable group.

Support Groups for the Addict's Loved Ones

Additional support groups exist for the families and friends of addicts, and their participation in these groups can actually assist in the recovery of the addict. The most prominent of these groups is Nar-Anon, which is also based on the twelve steps of Alcoholics Anonymous. Having usually spent years worried and agonizing over how to persuade their loved one to quit using heroin, people often turn to organizations such as Nar-Anon expecting to learn how to get their addict into a recovery program, or to ensure that their recovering addict remains clean. These people are often surprised, therefore, to hear that the most they can do to aid in their addict's recovery is to heal their own emotional problems—that they themselves are in need of a recovery program for the emotional damage that heroin addiction has had on their lives.

Loved ones of addicts have often developed an irrational, obsessive sense of personal responsibility for the addict's habit, recovery, and overall well-being. Often referred to as "codependency," this sense of responsibility can lessen the addict's sense of personal responsibility for his or her actions and addiction. Further, the obsession of codependency can affect virtually all areas of a codependent person's life, and can lead to a wide range of destructive and compulsive behaviors, such as workaholism and overeating. Also, codependency often leads to a wide range of stress-related illnesses, including migraine headaches, ulcers and other stomach problems, high blood pressure, depression, anxiety, insomnia, and even hyperactivity.

Thus, though often initially alarming for newcomers to programs such as Nar-Anon, the knowledge that they are powerless to prevent their addict's use of heroin can become a great source of relief. And, ironically, when addicts detect emotional detachment and recovery in their loved ones, they are themselves often unburdened of much of the guilt that can make it more difficult to become or remain clean. In this way, an addict's loved ones can significantly assist in the addict's recovery, though not in the way that they might have assumed.

Increased understanding of the complex emotional obstacles to effective recovery from heroin addiction is leading to even more comprehensive recovery programs. In the meantime, though still difficult, long-term recovery from heroin addiction can actually be a joyful experience for addicts. James W. West of the Betty Ford Center states this of the process of recovery from heroin addiction:

From sadness, isolation, and despair, many emerge through recovery to reach greater heights than if they had not fallen. Life in recovery is a mix of gratitude and serenity. People speak of an aura of wonderment as they experience an intense freedom from being sick in such an unpredictable, compulsive, and tragically self-destructive way. Life in recovery also brings loving and still hesitantly hopeful dear ones and friends back into reach. There is a humility that arises from the awareness of the depth of the illness from which revered persons arise. There is deep thankfulness to those who stuck with them. Coping with inevitable hard and even tragic times is part of . . . strong recovery. Eventually there comes that positive attitude that is so necessary to being a helper rather than a victim in society to which one now truly belongs and functions effectively.⁴⁶

Thus, the fact that recovery from heroin addiction is such a long and difficult process is not viewed by all recovering addicts as a burden. In comparison to the period in which they were using heroin, during which they may well have felt as if they were in the process of dying, recovery brings many addicts the sense that they are in the constant state of becoming something more than they were the day before—that they have never felt so alive.