Chapter Four:

Or Something - Treatment Options

ABSTINENCE ORIENTATED TREATMENTS
DETOXIFICATION
NARCOTICS ANONYMOUS
THERAPEUTIC COMMUNITIES
ALTERNATIVES TO ABSTINENCE
METHADONE MAINTENANCE TREATMENT
WHAT HAPPENS WHEN COMMENCING METHADONE?
'PROBLEMS' WITH METHADONE
METHADONE: RESEARCH AND MYTHS
PRESCRIBED HEROIN AND OTHER OPIOIDS

ABSTINENCE ORIENTED TREATMENTS

A number of addicts are able to recognise the problem and do something about it. Some move to the country for a spell. This is called a 'geographical'. And it sometimes works. Other times, however, when the person returns to familiar surroundings, they also return to old habits.

Another method is to go into a detoxification ('detox') unit where there are like-minded people, a comfortable bed and supportive environment to face the symptoms of withdrawal. This usually takes five to ten days in the case of heroin or alcohol. Withdrawals from long-acting drugs such as tranquillizers or methadone may take more than a month.

When necessary, most addicts can wean themselves down to a low dose of their drug-of-choice. From this point some can spontaneously cease drug use altogether. However, given the circumstances, many will return to drug use unless some protective mechanism has been set in place.

Hence it is important not only to obtain sobriety, but to maintain it by using any means possible. One common method is for the addict to hand over responsibility for their finances to someone else such as a spouse. Another effective strategy to avoid a return to drug use is participation in a formal self-help program such as Narcotics Anonymous.

DETOXIFICATION

Formal 'drying out' can be accomplished in the hospital or hostel environment. The supports provided vary according to the principles followed by each establishment. Most however, connect with a Twelve Step or Narcotics Anonymous (NA) program for those who are so inclined. This involves utilising the 'pain' of drugs as a 'gain' towards abstinence, and is highly successful for a proportion of addicts.

Numerous patients have been helped to detoxify at home by family members. Some may be new to the process and are often unsupported by outside services. Occasionally, the addict's family members are so affected by their loved-one's appearance, that they buy some heroin to relieve their relative's suffering. This, of course, is counter productive, and it puts an enormous responsibility onto those involved. They would be well advised to consult medical and self-help services during this difficult time. Some institutions will even supervise and medicate an out-patient detoxification program at the patient's home. The local doctor may also be involved.

It is almost impossible to quit two habits at the same time without support. For those with multiple addictions, such as heroin, nicotine and tranquillizers, home detoxification is inappropriate. It is preferable for the patient to be admitted to a detoxification ward for supervision of this complex process.

There are two types of in-patient detoxification, medicated and non-medicated. The medicated variety may use narcotics or non-narcotics to cushion the unpleasant symptoms of withdrawal. It should be understood, however, that the use of any narcotic drug during this process will usually lengthen it. Hence many addicts and carers believe that it is best to use no drugs at all.

The main problem during this period is lack of sleep. Some recovering addicts state that it took six months before they had a normal night's sleep after stopping drugs. Unfortunately, sleeping tablets are not appropriate for these people. Such medications are generally from the benzodiazepine family of drugs which are all addictive. Such tranquillizers can be more harmful than narcotics. This is especially so when they are taken in high doses or when they are used over long periods of time, even at recommended doses. Useful non-drug methods of treating withdrawals include massage, hot baths and other physical manoeuvres.

Apart from insomnia, the usual accompaniments of detox from narcotics are depression, debility (fatigue), diarrhoea and dolor (Greek for pain). Some are troubled by backache, headaches, or abdominal pains which must be distinguished from medical or surgical causes. These always wane with time, as long as the subject remains drug-free. Fits do not occur from narcotic withdrawals, but are regularly seen with those who have abused tranquillizers or alcohol.

There is little relation between the quantity of drug habit, the length of time drugs were used and the severity of symptoms in withdrawal. Some addicts describe symptoms similar to a mild influenza, while others used superlatives and expletives to emphasise their suffering.

Non-narcotic drugs which have been recommended for these symptoms are paracetamol, clonidine, lofexidine and various vitamin combinations. None of these is dramatically effective. The long acting tranquillizer, diazepam (Valium) is used sparingly in many detox units for the first night or two. A synthetic narcotic, propoxyphene (Doloxene) is also occasionally used.

NARCOTICS ANONYMOUS

Each 'member' attends a meeting of recovering addicts. The only condition for acceptance is a desire to stop using drugs. At the gathering it is possible to simply be an observer, while active members will recite their story out-loud to the group. New members are encouraged to share what they are going through. Some find that they need to attend meetings daily at first. Since most groups meet weekly, this means going to several different groups for a time. Continuity is kept by a 'sponsor' who can share day to day stresses by being available in person or by telephone when needed. There are no fees and no coercion.

Narcotics Anonymous is an effective strategy for avoiding drugs after the detoxification period is over. As with dieting, quitting cigarettes or other significant behavioural modifications, it is the 'long haul' which really matters for favourable outcomes. People who develop problems with excessive cannabis use often identify well with AA groups.

There are many different self-help societies in Australia dealing with a multitude of behavioural problems using variations of the Twelve Step program. Pills Anonymous, Gamblers, Shop-lifters, Hand Washers etc. all have one thing in common. They accept the existence of their compulsive behaviour as a disease over which they have no control except to avoid the trigger factor completely. This is easy to define in terms of drug or alcohol use. For other behavioural disturbances, there may be some difficulty in determining where ordinary behaviour becomes pleasurable, stress-relieving or compulsive.

There are many sensible principles expounded by AA and NA which can be useful for those who are not actively participating in such programs. Such folklore includes the following:

• 'Take each day as it comes and do not plan too far into the future.'
• 'A lapse is not the end of the world.' 'One lapse does not mean a relapse.'
• 'AA is the only place you can go when you have been drinking and nobody will criticise you.'
• 'It is normal for an alcoholic to drink; it is abnormal for an alcoholic not to drink.'
• 'Do not swap the witch for the bitch.' (Pills for alcohol).

THE TWELVE TRADITIONS*

1. Our common welfare should come first; personal recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate authority - a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
3. The only requirement for A.A. membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
5. Each group has but one primary purpose - to carry its message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property and prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever nonprofessional, but our service centers may employ special workers.
9. A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio and films.
12. Anonymity is the spiritual foundation of all our Traditions, ever reminding us to place principles before personalities.

*(taken from Alcoholics Anonymous, 1939, AA World Services.)

THERAPEUTIC COMMUNITIES

The 'therapeutic community' or 'residential rehab' is a traditional form of medium to long term treatment for drug (usually heroin) addicts. They enter a residential complex which is often in the country. Part of the treatment is a complete separation from previous lifestyle, associates and work. Even family visits are strictly limited as segregation is integral to the philosophy.

After up to twelve months in this regimented environment the 'recovering addicts' graduate to a 'half-way' or 'safe' house in town. From here, trips out are only permitted when accompanied by other members to prevent relapse to drug use. As time goes on, solo visits are allowed as members rejoin normal society, resume education or gain employment.

For unselected patients the success rate of therapeutic communities is quite low. Those sent by court order to be admitted to such establishments are extremely unlikely to remain free of drugs for long periods. Even medium-term successes may be as low as 10%. This form of treatment is also expensive as it involves residential care over long periods. On the other hand, in well motivated and self-selected addicts, the success rates are substantially better.

It would be impossible to accommodate the estimated 100,000 Australian addicts in this form of treatment. Other means must be used for the majority of heroin users in need of treatment.

ALTERNATIVES TO ABSTINENCE

Although there are many valid approaches, the fundamentals in the area of drug addiction have been known for many years. There are some parallels between the treatment of alcoholism, smoking and heroin addiction. When choosing the type of treatment which is best for a particular addict, one must be unemotional and objective since what suits one may not suit another. In treating addictions, one type of treatment may be unsatisfactory the first time around but may be successful on the next occasion. This should not mean, however, that unsuccessful treatments should be repeated time after time when there are alternatives.

A very small number of addicts may benefit from medical prescription of specific 'antagonists'. Disulfiram tablets ('Antabuse' for alcoholism) and naltrexone treatment (for narcotic addiction and sometimes alcoholism) can help maintain sobriety once this has been achieved. These antagonist drugs are most effective when used under the supervision of a third party such as a family member or pharmacist. Despite its reported successes in treating both narcotic addiction and alcoholism overseas, Australian authorities have not yet licensed naltrexone for general use.

When other methods have been tried and failed, an alternative is to give maintenance doses of a safe 'agonist' drug. Alcoholics in withdrawal can be given tranquillizers temporarily (usually Valium) to prevent or delay the onset of withdrawal symptoms, including fits. Even alcohol itself has been given in certain situations where the likelihood of abstinence is low. This may occur when a heavy drinker needs hospitalisation for an injury, illness or operation. Such treatment is not successful in the long term treatment of alcoholism, although some alcoholics do trade one addiction for another.

Acceptance of continued use of intoxicants runs counter to the principles of Narcotics Anonymous. However, it does accept the subject's dependence and may involve a desire for a longer term abstinence. This might be called 'Step Zero' and is equivalent to the 'pre-contemplation' phase of tobacco quitters.

METHADONE MAINTENANCE TREATMENT

The use of methadone as a treatment for illicit opioid use is now widespread and highly successful. Methadone is an opiate drug with some of the same properties as heroin. Like heroin, methadone has a very low incidence of tissue or organ damage in humans. Unlike heroin, methadone is very long acting, and is best absorbed orally.

Like heroin itself 50 years earlier, methadone was first marketed by a German drug company. World War II made traditional middle eastern sources uncertain, so synthetic opioids were being sought.

Oral absorption of methadone is nearly one hundred percent while the 'half-life' is between 24 and 60 hours. Once-daily administration of an appropriate individual dose will abolish withdrawal symptoms without inducing euphoria.

The use of methadone in addiction treatment was first reported by Dr Vincent P. Dole in New York in 1963 ¹. He and his psychiatrist wife, Marie Nyswander, had both observed the poor results of traditional treatment of addictions. As a biochemical researcher in New York he witnessed the scene at the 125th Street Railroad Station. In the 1950s, Dr Nyswander had written a book about heroin addiction being a medical disease, worthy of more attention from doctors. They were both convinced that the extraordinary plight of heroin addicts must be due to metabolic factors.

Within eighteen months, the group reported dramatic, almost miraculous effects of prescribing the drug to intravenous heroin users. Their classic paper in the Journal of the American Medical Association is one of the most quoted in the medical literature, and with good reason. It still makes relevant and interesting reading today.

Dole's team found the transformation to be rapid and radical, with most of his patients returning to a normal way of life in all observable respects. Education was resumed, families reunited, employment found and, most importantly, the patients largely curtailed their use of injected heroin while taking daily doses of oral methadone.

In the thirty years since Dole's original study, many investigators around the world have confirmed his original findings ². It is believed that there were over 100,000 patients on methadone world-wide by the mid 1990s.

Back in 1980 however, some physicians were advocating low dose methadone and reduction doses over limited periods. Though this ran contrary to Dole's original principles of management, it was attractive to those morally opposed to 'medical maintenance'. It also appealed to funding agencies as a way of saving money. By 1990 the HIV epidemic had taken its toll and research was clear that these therapeutic inadequacies had disastrous consequences. Such out-dated practices have now been largely abandoned ³.

Various refinements have been incorporated into modern practice to improve the outcomes and reduce unwanted effects. These aspects include longer periods in treatment, higher (or lower) doses as appropriate, the treatment of intercurrent illnesses and the use of intensive psychosocial supports ⁴. Certain therapeutic situations require very close supervision while at other times patients are best left some freedom to direct their own rehabilitation. These are individual clinical decisions.

WHAT HAPPENS WHEN COMMENCING METHADONE?

Methadone is a medical prescription. Before commencing it, the addict must have an assessment with a doctor. This includes a history, physical examination and a supervised urine test. Because methadone is a narcotic, the doctor must also obtain permission from the health authorities before prescribing. This can usually be done on the same day. Patients are then seen weekly at first, while stable patients are seen less often.

Many physical and mental changes happen when the drug user comes into methadone treatment. For the first time in what may be a very long time, the patient is free of cravings. Starting doses are usually 30-40mg. The period free of cravings may be brief at first, but as the medication builds up in the body this period should extend to twenty four hours. This may take up to three weeks and is sometimes called the 'honeymoon period'. After this, there should be no 'compulsive' drug seeking behaviour. A number of patients will still partake in narcotic use if others around them are doing so.

It is easy to recognise when the patient has reached their optimal dose. Their appetite returns, they sleep well and they begin to concentrate on other aspects of life such as family, work, education and (non-drug) recreation. Doses vary widely but most patients stabilise between 20mg and 120mg. The dose level is not related to the 'degree of addiction', but to the rate of metabolism. Thus there is no relation between the quantity of heroin consumed and subsequent dose of methadone needed. Urine test results reflect the patient's drug use and can usually detect narcotics for six days.

'PROBLEMS' WITH METHADONE

A number of patients gain weight when on methadone. This is caused by a combination of factors including increased food intake and less exercise. There is no evidence that methadone has a direct effect upon appetite or overall metabolism. On the other hand, the use of illicit heroin undoubtedly causes weight loss. Thus when on methadone, some patients simply return to their 'normal' body mass. A proportion of patients actually lose weight when on methadone treatment. This is also unexplained.

The only common side-effects of methadone treatment are constipation and sweating. Hence attention to hygiene, diet and exercise is important for these patients. In the drug using life style, many have forgotten or neglected dental hygiene and personal cleanliness. Gentle reminders from those who care may have the desired effect.

Recommendations about diet should be simple, practical and acceptable to the patients. Compulsive illicit drug users eat poorly, preferring fast foods, candy bars and soft drinks to more healthy staples ⁵. All patients should be advised to eat two pieces of fruit per day. Those with bad constipation should also use a natural laxative such as prunes. Patients should be encouraged to drink sufficient water and to eat foods which are rich in fibre such as pineapple, sweet potato, carrots and bran-added breads. They should be reminded that most cereals have low fibre ratings, and should be supplemented with unprocessed bran.

All adults need regular exercise, methadone patients being no exception. This aids digestion, blood pressure and the general level of fitness. Twice weekly formal exercise should be recommended at low levels for two hours or at higher levels for one hour. This can be as simple as a long walk or jog. Others will prefer cycling, tennis, swimming or going to the gym.

When used in the treatment of drug addiction, methadone is often given as a liquid. This is largely for historical and paternalistic reasons since tablets are known to work just as well. The syrup contains the active drug along with sugars and flavouring, with alcohol and benzoate as preservative. The liquid is unpopular with patients. 'Take-home' bottles may leak or break. The sugars may worsen dental problems. One practical benefit of a syrup is to enable small dose alterations.

A liquid presentation is also a temptation for those inclined to inject their take-away doses. The thick syrup was not designed for intravenous use and can cause severe pain when injected. Studies have shown that the majority of previous injectors who enter methadone treatment attempt to inject methadone at least once. In most cases this has no long term consequences.

A small minority continue to inject for longer periods, sometimes without apparent harm. Some such patients describe withdrawal symptoms coming on earlier due to increased metabolic clearance by the body following injection compared with the same dose given orally. This is a clinical problem which is addressed by various manoeuvres.

The granting of take-home doses is a vexed question in clinical practice. There is constant pressure to allow such doses to save patients time and money, but too many too early in rehabilitation lead to numerous problems which can rebound on the patient as well as the treatment generally. Most patients can safely be given single-day take home doses once per week.

METHADONE: RESEARCH AND MYTHS

Both the safety and effectiveness of methadone treatment have been studied as closely as any medical topic. These investigations have revealed no permanent tissue damage from long term use of the drug. Apart from some minor constipation and sweating, there would appear to be no significant side-effects in the vast majority of those who take it ⁶.

Some members of self-help groups may utilise the draw-backs of methadone as a foundation to their individual decision to cease this and other forms of drug use. These sentiments may be appropriate in private motivational meetings, but they must never be used to persuade an individual against considering the treatment which can be life saving.

Drug dealers may have an interest in spreading stories about the supposed dangers of methadone. Misguided moral crusaders have also had a part to play in such myth-mongering. Addicts who join methadone treatment are a substantial loss to a lucrative black market. Rumours which have been spread include the 'rotting' of bones, teeth and bowels. Another story is that methadone is much more addicting than heroin and that nobody ever gets off it. Whether methadone is more or less addictive than heroin is like arguing whether spirits are more addictive than beer. It is interesting but unproductive speculation.

It is disappointing that the merits of methadone are still debated by those with no experience in the drug and alcohol field. Such ignorant people have succeeded in having methadone banned in certain areas such as Australia's Northern Territory and New Hampshire in the USA. This is to the great detriment of addicts and yields disastrous consequences for the wider community.

Large numbers of patients successfully complete methadone treatment every year. The average length of time in treatment is between one and two years. It is now known that compulsory reduction 'programs' have very low success rates and for this reason have been largely abandoned. A small proportion of patients seem to require methadone almost indefinitely.

Methadone should be seen as just one standard medical intervention for a complex behavioural problem. In many areas there are still restrictions upon doctors and patients which would be considered unacceptable in any other field ⁷. These include limits to the numbers treated, artificial dosing regulations as well as the need for prior approval from health authorities before commencing treatment in each and every case.

When the epidemic of HIV/AIDS was recognised, some jurisdictions investigated methadone treatment, realising the likely benefits and relatively low cost. In some instances, it was introduced in some haste, with little preparation due to the urgency of the public health problem. Large clinics were established to expand the availability to large numbers of patients. The supply was often still inadequate for the demand, turning some clinics into focal points for drug dealing and crime as some patients were refused treatment. This was a source of spurious criticism for those opposed to methadone since such troubles were largely due to a lack of adequate treatment positions rather than the methadone itself.

It is interesting to hear some of those who are not in treatment talking of the difficulties of being on methadone; the 'inability to travel', 'high cost' and 'side effects'. Most patients who join methadone treatment talk about the opposite: the freedom it gives, the money it saves and the relief from unpleasant reactions from street drugs. For stable patients, methadone dosing locations can be altered by simply making a phone-call and sending a prescription by post or facsimile. If the patient is travelling beyond their own health jurisdiction, a letter to a physician in the new state or country is usually sufficient to continue the treatment elsewhere on a temporary basis.

The miracle of methadone has to be witnessed to be understood. The change in the addict is often sudden and dramatic. The appearance, attitude, general health and social functioning may return to normal almost overnight.

Following months or even years of illicit drug use, it is important to have a substantial period of stability on methadone before considering dose reductions. It has been shown repeatedly that those remaining in treatment longer have a better likelihood of long term abstinence from narcotics.

PRESCRIBED HEROIN AND OTHER OPIOIDS

The prescription of heroin for addicts is nothing new. Doctors have been doing it all this century in Britain. There has been little good analysis and only one randomised trial which compared legal injected heroin with oral methadone ⁸. This study showed comparable results in both groups after a year in treatment.

Another carefully controlled study was commenced in Switzerland in 1994. Injected heroin was prescribed to over a thousand heroin addicts in the clinic setting. All doses were for injection on the premises.

The candidates had to agree to initial randomisation into injected heroin, morphine or oral methadone groups. They then attended from one to three times daily for medication.

Preliminary results announced in 1996 were very positive. Patients' health, employment, legal and social parameters all improved. A number of patients also voluntarily transferred from intravenous heroin to oral methadone. Some patients were not able to tolerate morphine due to unpleasant side effects which did not occur on pure heroin.

A similar pilot trial has been proposed for Canberra, with subsequent involvement of other Australian cities. Although this has received an unprecedented level of community support, political and administrative obstacles have postponed it indefinitely.

The initial benefit from legal heroin is that more addicts may be attracted into treatment. It may also be appropriate for certain patients who have not done well on methadone and who drop out of treatment. The re-introduction of heroin as an analgesic would also be welcomed by many clinicians. It is useful as a pre-operative medication as well as in palliative care.

Reports have been published of substantial numbers of patients being treated with alternative opioids such as buprenorphine, levomethadyl acetate ('LAAM' or long acting methadone) and dihydrocodeine. There are also individual case reports of addicts being stabilised on shorter acting opioids such as dextromoramide and morphine.