Chapter 4
Treatment of Narcotic Addiction

Nearly all narcotic addicts believe that they can stop using drugs any time they choose. As Zeina, a twenty-one-year old heroin addict asserts, "Rehabs r useless. . . . I don't need a rehab i know I can do it myself."³⁶

However, very few can break free from their addiction without help. Most long-term narcotic use causes changes in the brain that stay even after drug use has ended. These changes affect behavior, often compelling the addicts to use drugs even in the face of harmful consequences. Therefore, the addicts who are most successful at dropping their drug habits are those who enroll in a supervised treatment or rehabilitation program.

The First Step Is Detox

Regardless of which treatment program an addict uses, detoxification is the first step. Detoxification is the elimination of the drug from the addict's body, a move that in the long run helps reduce the cravings for more of the drug. The process is difficult because it causes withdrawal symptoms as soon as an addict's last dose of narcotics has been metabolized. Although rarely life threatening, withdrawal can be so physically painful and emotionally exhausting that many addicts return to drug use just to end it. Therefore, detoxification is best accomplished in a setting that provides medical supervision and emotional support.

A few people are able to simply stop using narcotics, or go "cold turkey." However, this method is uncomfortable and few addicts endure it. Most undergo a supervised detoxification process in one of two ways: without the assistance of medication or with it. Those who do not use medication gradually reduce the size of their dosage over a period of time. Eventually, they quit taking the drug. Addicts who find this process to be too slow or difficult may choose to have the assistance of medication.

Roadblocks

One type of medication used in detoxification flushes the narcotic out of the addict's body. It works by occupying the opiate receptors in the brain and spinal cord, displacing the narcotics at their binding sites. Such chemicals, called opioid antagonists, are similar in structure to narcotics. Unlike narcotics, these medications are not drugs of abuse. They do not stimulate the cells they bind to, so they are not capable of causing a high or relieving pain.

Opioid antagonists are able to remove narcotics from their binding sites because they are more strongly attracted to opiate receptors than narcotics. Consequently, if heroin and an opioid antagonist are both present, the antagonist will bind to the receptor, leaving the heroin without a point of attachment. As a result, heroin has no effect on the cells.

As soon as a doctor administers an opioid antagonist to an addict, the patient begins to experience the discomfort of withdrawal. Withdrawal can be a tough experience. As one addict remembers, "Withdrawal from opiates is not life threatening—but it is an utterly miserable experience. You only feel like you're going to die."³⁷ To ease the process, the patient can be given other medications that help reduce pain and anxiety. Many patients remain under a doctor's care until withdrawal has passed, a matter of days or weeks, depending on the patient.

A commonly used opioid antagonist is Narcan. It cannot be absorbed from the digestive tract, so it is administered by injection. Since its effects last for only fifteen to thirty minutes, it must be administered repeatedly. Naltrexone, or Trexan, is similar to Narcan but it can be given orally, and its effects last much longer.

In a new procedure, some doctors put patients through a rapid detox. Ordinarily, a quick detox from narcotics would be unbearably painful. But in the new procedure, patients are kept under anesthesia while their bodies go through the worst stages of withdrawal. Naltrexone is given intravenously while the addict remains in an anesthesia-induced sleep for four to six hours. The advantage of rapid detox is that patients go through the worst stages of withdrawal, which include nausea, vomiting, cramps, and chills, while asleep. After rapid detox, residual amounts of narcotics remain in the blood for several days. If these rebind to the receptors, addiction will occur again, making the entire

No Pain

After interviewing the Green Bay Packers' quarterback Brett Favre in May 1996, Peter King wrote about Favre's drug addiction in "Bitter Pill." The article was reprinted in The Reference Shelf, Substance Abuse, a compilation of articles on drug abuse. In the interview, King learned about the events that led to Favre's abuse of narcotics and his subsequent treatment.

In May of 1996, Brett Favre knew he had a drug problem. One minute Favre was talking to his girlfriend Deanna Tynes, and the next he was lying in a hospital bed with tubes running out of his nose. Team physician John Gray leaned over his bed and said "You've just suffered a seizure, Brett. People can die from those." Favre knew his seizure was related to his addiction to narcotic pain-killers. He was finally ready to get help at the Menninger Clinic, a drug-rehabilitation facility in Kansas.

Favre, a football prodigy, quickly earned a reputation as a tough guy in football. However, this reputation was expensive. Between 1990 and 1996 Favre had five operations. Pain became a way of life for him. By 1995, Favre's old injuries were so painful that he started using Vicodin, a narcotic pain-killer, regularly.

Deanna had suspected Brett's drug problem for years. . . . Despite Deanna's pleas to get help, Brett felt sure that he could control his drug use and stay in the game. But the seizure got his attention, and he finally realized that he needed help.

Brett says, "People look at me and say, 'I'd love to be that guy.' But if they knew what it took to be that guy, they wouldn't love to be him, I can guarantee you that. I'm entering a treatment center tomorrow. Would they love that?"

After drug rehabilitation, Favre returned to the game he loves. Since 1996, the quarterback has admitted to, and dealt with, his narcotic addiction, putting him back on the road to glory.

detoxing process futile. For this reason, the addict continues to take naltrexone for a few days to prevent relapse. Naltrexone also insures that if narcotics are used after treatment, the addict will not get high.

David Costello describes the experience of one young lady in rapid detox:

Lisa Hill, a 27-year-old prescription drug addict, lies in a hospital bed in Tustin, about to undergo her third detox attempt. A few minutes later, doctors give her anesthesia, stick a breathing tube down her throat and then administer a liquid dose of Naltrexone. During the next few hours, the drug cleans Hill's body and brain of any remnants of the painkiller Vicodin that she has been hooked on since a car accident in 2000.

If Hill were awake, she'd be suffering hours of severe headaches, vomiting, shakes, sweats and relentless abdominal pain. The doctors, though, don't wake her for several hours, and later give her sleeping pills to make it through the night. In the morning, she wakes up, takes a shower and goes home. A few hours later, she no longer craves.³⁸

The treatment takes two days, from start to finish. "This is more successful than traditional treatments. And it's more humane," says Clare Waismann, director of the Waismann Institute in Beverly Hills, who brought the treatment to the U.S. five years ago from Israel, a major center of research into rapid detox programs. The number of patients undergoing treatment at the institute's clinic in Tustin has tripled in the last two years, Waismann says.

Rapid detox has its critics. Some physicians feel that it is dangerous for patients to remain under anesthesia for several hours. Others point out that it does not really matter how addicts detox; their success at beating drugs depends more on their ability to stick with a recovery program than on how they get the drugs out of their body. There are several recovery programs from which addicts can choose.

Methadone Treatment

Some of the oldest recovery programs for narcotic addiction are based on "harm reduction" approaches. The goal of all harm reduction plans is to change an addict's lifestyle so that it is safer and enables the addict to function in society. Methadone treatment was the first harm reduction program, and it is still in use today.

In methadone treatment, a less problematic narcotic is substituted for heroin or morphine. Methadone affects the body differently than narcotics of abuse. It binds to opiate receptors in the nervous system, stopping the painful withdrawal symptoms and the strong craving for other drugs. However, at the doses given in treatment programs, it does not produce sedation or intoxication. Addicts on methadone treatment can drive their cars, keep jobs, and participate in family duties. Unlike heroin, whose effects wear off in about four hours, methadone lasts about twenty-four hours; therefore, addicts just need to visit the clinic once a day to get their medication. This is an important aspect of the program for people who work or take care of children. Methadone can be taken orally, which is a benefit to those who need to get away from the habit of injecting a drug. Some individuals use methadone instead of heroin or morphine while they wean themselves off of narcotics. Others maintain a narcotic addiction by taking methadone for years, a program called methadone maintenance.

Chris, a twenty-three-year old, discusses his narcotic addiction and the results of his methadone maintenance program:

I've been doing heroin regularly since I was 17 or 18 . . . it didn't take long for me to lose everything I ever thought was valuable to me. . . . I lost my job, got kicked out of my folks house and then out of the friends house I moved into first. . . . i talked to my dad and told him I had had enough and I wanted to try the methadone program again, I had tried methadone before for a short time but just wasn't ready. . . . i've been on the methadone program for a year now. . . . I've had a job for a year and a place to live . . . i have the love and respect of my family and friends and self respect.³⁹

Since methadone programs have been useful for many addicts, research for an even better substitute narcotic has been ongoing. LAAM, which stands for levoalphaacetylmethadol, is a newer medication that can prevent withdrawal and drug cravings for seventy-two hours. Therefore, patients need only report to clinics two or three times a week. This helps remove them one step farther from their associations with other abusers and gives them more freedom in their lives. Buprenorphine, a newer release, is similar to methadone and LAAM, but has even fewer narcotic effects than either. It is hoped that buprenorphine will be especially useful in lowering a patient's physical dependence on narcotics.

Chemistry Can Help

In "Treatment Offers Same Results, Fewer Side Effects" (December 10, 2002), NBC News carried the story of the newest chemical breakthrough for narcotic addicts. Praised as easy to use, the new drug, buprenorphine, holds a lot of potential. A recovering addict,

[Otis] Rivers is now trying to get the word out about buprenorphine. Rivers joined a panel of experts from the Department of Health and Human Services and the U.S. Drug Enforcement Administration to unveil the new medical treatment for people addicted to opiates such as heroin, and prescription painkillers like oxycontin and vicodin.

Methadone, a painkiller, is the standard drug for treating opiate addiction right now, and has been for many years.

Dr. George Kolodner, the director of Chemical Dependence at Georgetown University Hospital, said buprenorphine, an analgesic, is a big improvement.

"It's just as effective as methadone in relieving the withdrawal symptoms of whatever drug the person is using. But unlike methadone, the withdrawal symptoms from buprenorphine are relatively minor," Kolodner said.

"There are people who are on painkillers and they want to go off painkillers and they are not quite sure what to do about that. To go to a specialized methadone clinic is sometimes a fairly protracted [drawn out] situation, where if they just go to their doctors it would be easier for them to get off," Kolodner said.

Rivers said buprenorphine gave him a new life. Today, he hopes this new program will help thousands of people fight their drug addictions.

The Controversial Side

Even though methadone, LAAM, and buprenorphine programs are accepted treatment plans for narcotic addiction, not everyone finds them satisfactory. Many feel that the only real treatment for narcotic addiction is total abstinence, and that substituting methadone for heroin or morphine is just swapping one narcotic for another. Some believe that maintenance does not address the addict's real problems. In their book From Chocolate to Morphine, authors Andrew Weil and Winifred Rosen explain the shortcomings of the methadone program.

The main advantage of methadone maintenance is that it is better than leading a criminal life. The real problem with it is that it doesn't go to the root of addiction. Nor does it show heroin users how to get high in any natural, less restricting ways. It offers them no help with the problems that led them to abuse heroin in the first place. All it does is substitute one narcotic for another; the addict remains an addict, albeit in a less destructive way.⁴⁰

Like other narcotics, methadone and its relatives lead to physical dependency. One strong argument against them is that addicts who want to be completely free of narcotics find withdrawal to be as, or even more, difficult as withdrawal from the original drug of abuse.

One veteran addict describes how hard it is to get off of methadone:

I've been on both ends of withdrawals, heroin and methadone, every patient of methadone will always tell you the same, as I do; I can kick heroin anytime, but methadone that is something else. In 15 years of heroin addiction, I've kicked three times, "cold turkey." In 10 years of methadone, I've never kicked methadone. Once I landed in jail, I had to do 72 hours of jail time before I got to see the judge. I was literally on the floor screaming my guts out. About 12 hours before I was to see the judge, I demanded to be taken to a hospital, I just couldn't take it. I was cuffed, and looking like "chair" was glued to my back, I limped to the ambulance, since I couldn't lift my leg to climb in the back, the police grabbed me on both sides and shoved me in like a sack of potatoes, I fell flat on my face. The doctor, realizing my condition and that it was severe, gave me a shot of methadone. The relief was immediate.⁴¹

Behavioral Therapies

Professionals recommend that any narcotic addict seeking recovery enroll in a behavioral therapy program. Behavioral therapy offers understanding and emotional support to the addict, while teaching new techniques for coping with life without narcotics. There are many kinds of behavioral therapy. Some are available from professional counselors and medical practitioners. Professional programs can be operated on either an inpatient or outpatient basis. In an outpatient program, the patient attends a clinic or program in the daytime, then goes home every night. Such programs work well for people with jobs or children. Many of these are supported by hospitals, communities, and local governments. In residential or inpatient programs, the addict lives at the treatment center for a few weeks or months. Odyssey House, Daytop, and Phoenix House are residential centers where addicts work together to build a new life. Both in- and outpatient programs have proven successful, so addicts choose the one that best fits their needs.

In New York, homeless addicts have access to a comprehensive residential treatment program that includes detoxification, methadone, counseling, emotional support, and continuing education. Kevin Rivers is one of New York's many success stories. Counselors describe the changes in Kevin's life:

Kevin Rivers started down the wrong road early: he shot heroin at the age of 12. Unfortunately, giving it up was not as easy, and Kevin spent the next 32 years either on drugs or in jail.

After being released from Riker's Island [prison] the last time, Kevin went to Bellevue Men's shelter. By now, Kevin was on methadone maintenance to control his heroin addiction. While at Bellevue, he heard a speaker from Project Renewal talk about their new program at Kenton Hall—a modified therapeutic community for homeless men on methadone—the first in the city, and probably the country. But . . . he was still using [heroin].

His case manager . . . never gave up on him and gave him constant support. [Kevin says,] "I don't know, I guess she saw something in me that I didn't see." Kevin had joined the culinary arts program but was coming to class high. He was pulled out of class. His case manager and other counselors convinced him to detox. He completed detox, was let back into culinary arts, but again got caught using. His case manager and counselors took him on . . . again. Kevin couldn't understand why they cared so much about him when he didn't. [He said,] "After that I never picked up again. From there it was an uphill battle."

Kevin became immersed in the culinary arts program. [He explained,] "I just needed something to do." Whenever he felt the urge to get high he picked up his books. He just kept reminding himself of what he had to do. After a while he didn't have to remind himself so much and realized that he liked studying and learning more than he liked worrying about getting high. Other people started to notice the change as well and supported him. This made Kevin feel really good. He started to like himself again. [Kevin said,] "I know I can't change the past and what I have done but I can change the future and my way of thinking." He is now working part time and hopes to be hired full time. [He asserts,] "I am a miracle."⁴²

Narcotics Anonymous

Several self-help behavioral therapies are conducted by nonmedical personnel. Narcotic Anonymous (NA) is a community-based program made up of former addicts who assist current addicts in getting off and staying off of drugs. In 1947 in Lexington, Kentucky, the first NA meeting was conducted with federal funds by counselors in the public health service. Today, members of NA work closely with medical professionals and social workers who help individuals take twelve specific steps to reach a drug-free life. The goal is to support addicts on their quest for a new, more satisfying life without drugs. There are more than twenty thousand facilities located in seventy countries.

One user tells his story, which is similar to the experiences of other NA members:

My name is Brian and I'm an addict. I choose not to use drugs today. These two sentences give me the right to belong to NA. In the 12 Traditions of Narcotics Anonymous, it says "The only requirement for membership is the desire to stop using." I have that desire.

I spent 14 years in active addiction, and for almost every day of those 14 years I used drugs. When I first started using, I thought they were the greatest thing on earth. I still remember thinking that first time that I would never need to rely on anyone to make me happy ever again. All I needed was my drugs. I used daily from the start. . . . Within a year, I knew I was in trouble and unable to stop.

I could no longer relate to being straight. Normal for me was to be stoned on drugs. There came a time when I had finally had enough and I realised that I would never stop on my own as I had finally accepted to my very soul that I was powerless over drugs and I needed help.

I went for treatment. . . . I was also introduced to the 12 step programme of Narcotics Anonymous. I was told to go to NA when I left treatment if I wanted to stay clean. So I did. I have stayed clean and sober for nine years now on a daily basis thanks to a loving God and the people in NA.⁴³

Help Is Everywhere

On March 11, 2002, ABC news reporter Alexa Pozniak shared the success story of one young heroin addict in "Help Is Out There, Treatment for Young Drug Addicts."

By the age of 18, Melanie was a recovering drug addict who had been using both street and prescription drugs for more than five years.

She said, "Drugs were ruining my life. I lost a lot of friends, my relationship with my parents was ridiculous. Everything seems to crumble and you don't seem to realize it . . . I found out about a clinic from kids on the street."

The treatment program that Melanie sought out . . . is funded by the National Institute on Drug Abuse to develop an effective treatment program for young addicts. . . . The 28-day program is set up so that kids are given a combination of medical detox, which includes medication, and lots of intensive counseling.

Although she had been a drug user for many years, Melanie admits her parents never knew about it. . . .

"I told them the day before I entered treatment and they were totally shocked," she says, adding that her parents were very supportive throughout her treatment. . . .

As Melanie looks back, she wishes she received more education about drugs.

"I can't emphasize enough how much these kids have no idea what they're getting themselves into. If I had known what heroin does to people, I probably wouldn't be sitting here talking to you. Kids need to know that they can go anywhere for help, guidance counselors, teachers, friends. The information and help is out there, everywhere. Even though it's intimidating to go up to someone and ask for help, it's important."

Needle Exchange

One focus of harm reduction programs is to help people stay as healthy as possible. Maintaining good health involves many practices, such as adequate nutrition, basic medical care, and the resources to avoid exposure to diseases. Addicts who inject drugs are at risk of contracting contagious bloodborne diseases. In fact, three-quarters of all new cases of AIDS result from intravenous drug use. Addicts who do not have access to clean needles may inject with needles that other people have used.

To slow the spread of bloodborne diseases, more than one hundred cities in the United States have set up clinics to exchange used needles for clean ones. Addicts can also pick up alcohol swabs and get medical advice on the safest ways to shoot up. The Washington State Department of Social and Health Services presented evidence to support the usefulness of needle exchange clinics, stating that,

Studies have shown that cities which implemented needle exchange programs early in the AIDS epidemic have much lower infection rates among injection drug users than those who waited to implement them. Needle exchange programs act as gateways to drug treatment and other services. Exchange sites are the leading source of drug treatment referral in Washington State.⁴⁴

Many residents of neighborhoods near the treatment centers are not thrilled with the programs, claiming that the centers attract drug users. Nancy Sausman of New York City's Lower East Side says that the programs are "distribution centers for needles and drug paraphernalia. They have nothing to do with health and only work to bring down communities."⁴⁵ James Curtis, director of psychiatry and addiction at Harlem Hospital Center in New York City, also opposes the program, stating that "Addicts need to be treated. . . . They should not be given needles and encouraged to continue their addiction."⁴⁶

Safe Injection Sites

An even more controversial harm reduction proposal is the establishment of safe injection sites (SIFs). Some countries, including Australia, Switzerland, Germany, and the Netherlands, already have such programs, and Canada is considering them. At these sites, addicts can bring in their drugs, inject using clean equipment, and receive supervision from medically trained personnel. The drugs are not provided for clients by the SIFs, and the staff cannot administer the drugs. Like needle exchange programs, SIFs provide clean equipment. Personnel at these sites also counsel clients, provide medical care, and help get those who are ready into treatment programs.

Critics of SIFs feel that the centers merely encourage drug use and attract addicts to the area. Advocates of SIFs explain that the medical staff helps reduce overdoses and the spread of contagious diseases. The facilities also get addicts off the street and provide a safe place to dispose of used needles.

The director of a new SIF in Sydney, Australia, says that in the first six months of operation, the facility has already saved the lives of 36 people who had overdosed. With 831 registered to use the site, the medical staff sees about 100 people each day. Of these, they have referred 258 to addiction treatment services, health care facilities, or social services for help.

The Whole Picture

Narcotic addiction is a national health problem, yet no one knows the best way to treat it. The most successful programs are those that combine detoxification with support techniques that fit each person's lifestyle and goals. Both chemical and behavioral therapies play important roles in recovery from narcotic addiction.

The future looks hopeful. Research on drug addiction treatment continues. Scientists have already discovered the genetic information that creates opiate receptors on cells. They plan to use this knowledge to make copies, or clones, of receptors in the lab where they can be closely studied. With a better understanding of how receptors work, scientists will be one step closer to understanding the mechanisms of narcotic addiction and discovering more successful treatments.