Sober N Clean

State's only public treatment system says 93% of patients aren't using other opiates

A client of the Charleston Center of Charleston County takes a dose of methadone.

When he tried to quit using OxyContin, heroin and other opiates cold turkey, Ken S. said the pain was so great he felt it in the marrow of his bones.

Ken, 40, who chose not to give his last name so he could remain anonymous, said that about a year ago he landed on the doorstep of the Charleston Center of Charleston County, a drug and alcohol treatment program that runs the state's only public methadone program.

He had been abusing opiates since he chugged a bottle of codeine cough syrup at 10 years old. And he was at the end of a two-year spree of heavy abuse of prescription opiates and heroin that left him in fear of losing his job and his family.

He was so out of control, Ken said, that he physically and verbally abused his wife as his child watched. "My 9-year-old son was scared of me," he said.

Ken was so ashamed of what he'd done that he tried to stop using the drugs, but the withdrawal symptoms were unbearable. He found himself doubled over and vomiting in the shower as nearly scalding water washed over him.

"It was disgusting," he said. He knew then that he desperately needed help.

He remembered hearing that a former girlfriend, who also was an opiate addict, had participated in a methadone program and was successful getting off the drugs.

So, Ken showed up at the Charleston Center. It was his last hope, he said, "the last house on the block."

Ken said he hasn't abused drugs in about a year. And he takes the methadone only as prescribed.

He's rebuilding his life with the help of the methadone program, which includes counseling and regular drug screening. He also is part of a 12-step recovery program. For the first time in many years, Ken said, he can think about doing things to help others instead of simply thinking about himself and planning to get more drugs.

He's aware of the stigma surrounding methadone programs, how they conjure images of homeless junkies injecting themselves with heroin.

Ken is employed, middle class, married and has never used a needle. He thinks the negative stereotype keeps other addicts from seeking the help they need.

Methadone, a long-acting synthetic opiate, has been used to treat heroin and other opiate addicts since the 1960s. Some addicts treated with methadone gradually decrease their dosage until they are drug-free while others stay on it for decades. They don't get high from methadone, and are able to function normally, including holding jobs.

According to the White House Office of National Drug Control Policy, methadone is a rigorously well-tested medication that is safe and efficacious for the treatment of narcotic withdrawal and dependence.

Still, it remains controversial with the public and among some alcohol and drug treatment professionals who believe that only abstinence-based programs are effective.

Dr. Jack Emmel, medical director of the Charleston Center, winces when people ask him whether treating heroin and other opiate addicts with methadone is simply trading one drug for another.

When it comes to opiate addiction, he said, "you'll find no program that has the success rate of a good methadone program."

Addiction to shorter-acting opiates, which include heroin, OxyContin, Lortab and Vicodin, severely alters a person's brain chemistry, he said, while methadone stabilizes it.

Methadone, however, doesn't work quickly. It takes many months, even a year in some cases, for an addict's brain chemistry to return to normal, Emmel said.

Addicts who attempt to stop using opiates too quickly experience severe withdrawal symptoms and are likely to return to abusing the drugs, he said. Ninety percent of such addicts who stop cold turkey, even those whose withdrawal is medically supervised, relapse, he said.

Ed Johnson, program administrator for the center's opiate treatment program, said patients who use methadone fare better.

The center's random drug tests have found that 93 percent of patients who are using methadone aren't using any other opiates. And 65 percent aren't using any other drugs. Those rates indicate that the methadone program is more successful than most drug treatment programs, not just programs for opiate addiction, he said.

Johnson said the stigma surrounding methadone programs has worsened after some recent highly publicized drug overdose deaths involving methadone and other drugs.

Methadone also is used as a painkiller, he said, so it ends up on the street. But most addicts use it only when no other opiates are available. It doesn't give them a good high, but it holds off painful withdrawal symptoms, he said.

Johnson and Emmel said the center's staff thinks gradually decreasing the dosage of methadone and becoming drug-free or staying on the drug long-term are both viable options.

"A person whose methadone dose is adjusted properly is 100 percent functional," Emmel said. And some people can't get off it, just as some people with diabetes can't eliminate the need for insulin by changing their diets and exercising.

The center serves about 250 patients in the methadone program, Johnson said. They are all different ages and come from all walks of life. Fewer than half use needles. Most abuse prescription drugs.

The state has 10 private methadone programs, including one in Charleston.

The Center's program is self-supporting, and patients pay about $13 per day, Johnson said. That includes methadone and counseling. Without counseling, most patients would likely relapse, he said.

Ken says that's true for him. In the year he's been on methadone, he's been "working full-throttle on recovery," he said. He's been decreasing his dosage of methadone over the past several months, and expects to be off of it and completely drug-free by mid-August.
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source: Charleston Post and Courier, http://www.charleston.net

It is unusual for politicians to face up to the obvious, but the Scottish Executive seems for once to have done so: it has recognised what has long stared it in the face, namely that dishing out methadone to drug addicts is not the answer to their problems or to the problems that they cause society. A different approach is needed.

Perhaps in 100 years historians will wonder why so many of the governing elite, from senior doctors to Cabinet ministers, persisted for so long in the belief that doling out methadone was the answer. The explanation, I think, will be that they wilfully misunderstood the nature of the problem.

Many years ago I used to dole out methadone like the best (or the worst) of them. This was before I thought at all deeply about the question of drug addiction and accepted uncritically all that I had been taught about it by doctors senior to me. I began to change my opinion when I worked in prison where it was the clinical policy to give addicts methadone. I noticed that, far from creating an atmosphere of contentment and satisfaction, it created one of perpetual tension and irritation. Shortly after having been prescribed a dose, the prisoner would return and say, in an intimidating fashion: “It's not holding me, doc, it's just not holding me,” and sometimes announce that, unless he was prescribed more, he would end up attacking other prisoners, and then it would be the doctor's fault.

In Scotland the great majority of addicts prescribed methadone by their doctors never stop taking it, and most of them take other drugs as well. A particularly dangerous combination of drugs is methadone and benzodiazepines (drugs such as Valium), and yet drug clinics and other doctors persist in prescribing this often fatal combination - largely, I suspect, because they are too frightened of their patients to refuse them anything.

The number of people admitted to hospital having taken a dangerous overdose of methadone (556 in 2006-07) is greater, proportionately, than the number of people admitted to hospital having taken a dangerous overdose of heroin (1,530 cases). In Dublin recently, more people have died of methadone poisoning than of heroin overdose. The supposed cure causes as many problems as the supposed disease. If addicts prescribed methadone are given the opportunity to divert it on to the black market, they will: which suggests that they do not really need it in the first place.

In France, addicts are often prescribed a different drug, buprenorphine, which soon became the street drug of preference in Finland, to which it was illegally re-exported by the addicts. More recently, a huge epidemic of buprenorphine addiction has occurred in Georgia (the ex-Soviet republic), numbering scores of thousands of addicts, who take buprenorphine diverted from France. If the addicts really needed the drugs, they would take them rather than divert them on to a black market.

In the prison in which I used to work, a buprenorphine tablet that had been prescribed for an addict to alleviate the symptoms of withdrawal from heroin on arrival in the prison, and which an addict had put in his mouth and spat out for sale to another prisoner, was known as a “furry” because of its rough surface. Again, this suggests that addicts did not really need what they were prescribed, and that the whole basis of prescription was flawed.

The fundamental error that the Scottish Executive has now admitted is in having regarded addiction to heroin as a technical medical problem, to be solved by technical medical means. But that old approach amounts to a surrender to blackmail: give me what I want or I will continue to behave badly and to hold you responsible for the ill-effects of my own behaviour.

Suppose we gave money to burglars to induce them to stop burgling. No doubt most of them would stop for a length of time depending upon how much we gave them. But this does not mean that money is the treatment of the dreadful disease of burglary, or because we prevented certain individuals from continuing to burgle it means that we had reduced the disease of burglary in society as a whole. Rather, we would have encouraged its spread.

This is precisely the logic that has been applied to drug addiction. Just how precisely is evident from the Government's recent declared policy that clinics should now give drug addicts money or other rewards for not taking drugs (as least as proved by drug-free urine samples, something experienced drug addicts have long learnt to provide). This is the first time in the history of medicine, so far as I know, that bribery has been considered a medical treatment.

Contrary to what everyone supposes, withdrawal from heroin is not a serious medical condition - unlike, say, withdrawal from alcohol when it results in delirium tremens (the DTs). The suffering is grossly exaggerated and, in so far as it is genuine, is largely produced by anticipatory anxiety that is itself the consequence of years of mythologising the fearsomeness of withdrawal.

Addiction to heroin is a medical problem only to a minor extent, which is why predominantly medical means will never solve the problem. Most of Britain's 300,000 addicts are drawn from broken families, have a poor education, are without much hope for (or for that matter fear of) the future and have no cultural life, intellectual interests or religious belief. Delusory euphoria - the paradise at three pence a bottle that De Quincey described in his Confessions of an English Opium Eater - is the best that they think that they can hope for in life. This is not a medical problem. Where addiction is concerned, it is time to throw physic to the dogs.
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author: Theodore Dalrymple is a retired prison doctor and author of Junk Medicine: Doctors, Lies and the Addiction Bureaucracy

source: Times Online