Pubdate: Tue, 29 Jan 2008
Source: San Diego City Beat (CA)
Copyright: 2008 San Diego City Beat
Contact:  http://www.sdcitybeat.com/
Details: http://www.mapinc.org/media/2764
Author: Kelly Davis

THE POLITICS OF ADDICTION

Methadone Is the 'Gold Standard' For Getting Addicts Off Heroin--Just 
Not in San Diego County

No one's quite sure how addiction works--why among a group of friends 
who share a few lines of coke or a balloon of heroin at a party, one 
becomes an addict and the other nine never pass the point of being 
recreational users. Or why one person can toss out a bottle of 
leftover Vicodin once he's recovered from his back sprain while 
another finds himself doctor shopping for prescriptions, unable to 
function without more and more pills. Genetics and environment play a 
role, though there are always exceptions to the rule.

One thing is certain: Addiction changes a person's brain chemistry to 
the point where the brain can't function normally without the drug. 
Drugs become all a person thinks about because they are, literally, 
all the brain wants. Few addictive substances take over the brain 
quite like heroin.

"Telling a heroin addict to just say no is like telling someone who's 
bipolar to have a nice day" is how Dennis Whitmyer puts it.

Whitmyer is the Southern California director for CRC Health. CRC 
operates five drug treatment facilities in San Diego County serving 
roughly 1,500 addicts, the majority of whom show up every day, 365 
days a year, to receive a dose of methadone in the form of a pink, 
cherry-flavored liquid that they count on to keep their drug cravings at bay.

Last October, the same week wildfires broke out around San Diego 
County, a couple thousand doctors, nurses, drug counselors and public 
officials gathered at the San Diego Sheraton for the annual meeting 
of the American Association for the Treatment of Opioid Dependence 
(AATOD), the national trade organization for providers of what's 
known as medically assisted drug treatment. While there are a small 
handful of drugs used to treat opiate addiction, methadone is the 
biggie and received much of the focus at the conference, where 
featured speakers comprised a who's-who of the drug-treatment world, 
from the current head of California's Department of Alcohol and Drug 
Programs to the director of the national Center for Substance Abuse 
Treatment. San Diego Mayor Jerry Sanders was scheduled to give a 
welcome speech, though he had to cancel because of the fires.

Whitmyer, who chaired the conference's hospitality committee, noticed 
an absence among attendees--no one from the County of San Diego, the 
region's overseer of public-health programs, signed up to attend.

"That was a national program that was attended by 2,000 people and 
there was no one from the county there, in our own backyard, to learn 
about the benefits of medically assisted treatment," Whitmyer said.

No one was there because medically assisted drug treatment, also 
referred to as narcotic-replacement therapy, is not a service the 
county provides. Politics and cost--likely more the former--appear to 
be the reasons why, and the county's not alone in its refusal to 
embrace what Kathy Jett, director of the Division of Addiction and 
Recovery for the California prison system, referred to as "one of the 
most stigmatized fields there is, despite all the research.""

Methadone, like heroin, is an opiate. Like heroin, it binds to opiate 
receptors in the brain; but, unlike heroin, it doesn't produce a 
euphoric effect. When used in a drug-treatment setting, methadone 
eases the debilitating symptoms of opiate withdrawal and, when 
accompanied by counseling, allows a recovering addict's focus to be 
not on the sickness and craving that accompany withdrawal but, 
rather, on getting her or his life in order. An added bonus of 
methadone is that since it binds to opiate receptors, an addict on 
methadone who injects heroin won't experience a high because the 
seat's already taken.

In medical literature and position statements by drug-treatment 
organizations and advocacy groups, methadone is referred to as the 
"gold standard" for treating opiate addiction, with studies pointing 
not only to its medical benefits, but social benefits as well. For 
instance, a study released last April by the National Institute on 
Drug Addiction found that heroin addicts who were wait-listed for 
treatment were more likely to actually enroll in treatment--and less 
likely to be involved in criminal activity--if they're put on 
methadone in the interim.

But, out in the real world, methadone's been plagued by problems of 
misuse and lingering stereotypes.

"When you start talking about methadone, everybody gets the same 
visceral gut reaction," said John Peloquin, vice president of 
operations for CRC's Southwest Division, "that it's a seedy-looking 
little facility that you go to the back door and knock on the door 
three times and you get your fix of methadone."

Though it's not available without a prescription, there's a high 
incidence of methadone street-sales to addicts looking for something 
to hold them over until their next fix. And, during the past decade, 
the drug has become a popular pain medication because of its low cost 
compared with other prescription painkillers. But, after a 
significant increase in fatalities from methadone overdose--up 390 
percent since 1998--on Jan. 1 of this year, the Drug Enforcement 
Administration put a moratorium on doctors prescribing methadone in 
non-treatment settings; pharmacies can no longer stock the drug, either.

Like the drugs it's designed to combat, methadone creates physical 
dependence--users must wean off the drug under a doctor's 
supervision--though the withdrawal symptoms aren't as severe as 
heroin withdrawal. Methadone's not a quick-fix for addiction, either. 
In one mid-'80s study involving 671 addicts, 92 percent of 
participants who stuck to a methadone-treatment program for 
four-and-a-half years stayed clean. But of the 105 patients who 
stopped methadone after one year, 82 percent went back to using 
drugs. In terms of publicly funded drug-treatment programs, having to 
make a long-term commitment to an addict might not sit well with taxpayers.

No one wants to be tied to a prescription drug for the rest of their 
life, Peloquin said--the goal is to stabilize a person and then start 
them on the process of weaning off methadone. But, "if a patient has 
20, 30 years of hardcore drug abuse, the patient's brain chemistry 
has altered so much that they may never find themselves off of 
methadone," he said.

San Diego is the largest county in California that neither provides 
medically assisted drug treatment nor contracts with any providers 
that do. Drug-treatment providers that get funding from the county 
operate under a drug-free model, also known as social-model 
treatment, meaning anyone enrolled in their programs must abstain 
from any substance that could result in dependence, even if that 
substance is helping them kick their habit. A person who enters a 
county drug-treatment program on methadone might as well have entered 
the program on heroin.

The drug-free treatment model carries over to the criminal justice 
system, too. San Diego County's Drug Court, a diversion program that 
offers nonviolent offenders the option to enter treatment rather than 
jail, forbids medically assisted treatment. And of the $9 million San 
Diego County receives annually to pay for Prop. 36--the statewide 
drug-treatment initiative that's based on the drug-court model but 
with more lenient probation rules--none of that money funds medically 
assisted treatment.

Of the state's 21 largest counties, San Diego is one of only five 
that doesn't allocate any money for narcotic-replacement therapy 
(NRT), even though state officials have consistently recommended that 
it be included as a treatment option because of its proven success 
rate. In a final report on Prop. 36's first five years, published 
last April, researchers from UCLA found that only between 10 and 15 
percent of Prop. 36-eligible heroin addicts were referred to NRT, but 
of that group, 71 percent successfully completed treatment. 
Meanwhile, 52 percent of heroin addicts who entered a drug-free 
treatment program successfully completed it.

"Heroin users' performance in treatment may improve significantly if 
NRT is made more available," the UCLA report concluded.

Susan Bower, head of San Diego County's department of alcohol and 
drug services, explained that the county doesn't fund medically 
assisted drug treatment because clients who opt to go that route can 
pay out-of-pocket or apply for state assistance. A 1994 legal 
settlement ordered the state to fund methadone treatment for anyone 
who qualifies for what's called Drug Medi-Cal, which has basically 
the same eligibility requirements as regular Medi-Cal.

"It doesn't mean there's any more or any less services because of 
that," Bower said.

Whether Prop. 36 clients know that self-funded or state-funded 
methadone treatment is an option isn't clear; a spokesperson for the 
county said that drug-treatment providers who contract with the 
county can refer patients to methadone programs if the provider 
thinks that's the patient's best option, but two law-enforcement 
officials who work with Prop. 36 clients were unaware of any sort of 
referral system, and a spokesperson for the California Department of 
Drug and Alcohol Programs said their records show that no San Diego 
County Prop. 36 participants have been referred to 
narcotic-replacement therapy between the program's start in 2001 and 
2006, the most recent year for which numbers are available.

The decision not to fund methadone is also a matter of limited 
resources, Bower said. "[If] we chose to take money from current 
treatment programs and shifted that over to fund methadone, that 
means waiting lists in other treatment programs."

Then there's the fact that heroin addiction isn't the epidemic it 
once was. As Richard McCue, a deputy district attorney who oversees 
three of the county's drug courts, said, "I don't want to sound 
cavalier about it, but within the context of the people we are 
working with, heroin addiction is rare. What we're seeing is 
methamphetamine, methamphetamine and more methamphetamine."

Methamphetamine may have surpassed heroin in numbers of new addicts, 
but prescription opiate abuse--OxyContin, hyrodcodone, Vicodin--is on 
a slow creep. In January, the Community Epidemiology Working Group 
(CWEG), a panel of researchers who track drug-use statistics from 16 
metropolitan areas, reported that in San Diego County, opiate 
addiction (separate from heroin addiction) was the only category of 
addictive drugs for which treatment admissions had increased during 
the past five years. And the Drug Abuse Warning Network, a 
drug-monitoring group that tracks drug-related emergency-room visits, 
reported that in San Diego County, opiate abuse landed more people in 
the ER (460) in 2006 than heroin (371) cocaine (342) and marijuana (432).

Jails are another story. In a study commissioned by the Drug Policy 
Alliance that's not yet been made public, San Francisco attorney 
Jennifer Schwartz looked at what options are available to jail 
inmates in 16 California counties who are addicted to opiates or who 
are already enrolled in a methadone-treatment program at the time of 
their arrest.

For the latter group, San Diego County jail inmates must arrange for 
a family member to bring them their daily dose of methadone, which is 
then administered by a jail nurse. That arrangement is available to 
"short stay" inmates only, Schwartz said, though she was unable to 
find any jail official who could tell her what constituted a short stay.

Last year, new law made additional money available for counties to 
spend on Prop. 36-eligible offenders who were slipping through the 
cracks. Called the Offender Treatment Program, the money came with 
recommendations, among them that counties offer narcotic-replacement 
therapy to heroin addicts who were violating probation. But it's only 
a recommendation, said Lisa Fisher, an ADP spokesperson.

"One of the hallmarks of Prop. 36 is local control," she said. "We 
would not tell [counties], 'You have to do this,' but we can 
certainly give them what our research has found to help improve outcomes."

Schwartz said that an impetus for the Drug Policy Alliance study was 
to examine whether jails should be mandated to provide methadone or a 
similar narcotic replacement to opiate-addicted inmates--both to 
stabilize them and start them on a treatment path.

"Our concern is what is happening to these people withdrawing if 
they're not being constantly monitored," she said.

"My overall impression was [the jails] are basically doing next to 
nothing, and the state department is really trying to get them more 
and more involved, as are the private providers, but they just don't 
seem very interested."

Jim Dunford, medical director for the city of San Diego, said inmates 
in downtown's Central Jail who come in addicted to heroin are given 
medication to ease withdrawal, though methadone's not one of them. 
"We make sure their withdrawal symptoms are being adequately managed," he said.

Schwartz found only two county jail systems--Marin and 
Mendocino--that had medically assisted drug treatment programs for inmates.

According to the San Diego Association of Governments' Substance 
Abuse Monitoring Program, while roughly two-thirds of county 
arrestees tested positive for drugs in 2006, only about 6 percent 
tested positive for heroin--a number that's remained unchanged since 
2004. But of that 6 percent, three-quarters said they preferred to 
inject heroin, as opposed to snorting or smoking it. The most recent 
CEWG report found, too, that more heroin addicts in San Diego County 
are opting to inject the drug--likely because it produces the fastest 
high. According to CEWG, 82 percent of heroin addicts who entered 
treatment in 2006 said they preferred to shoot the drug--a 10-percent 
increase from 2005. This put San Diego County fourth among large 
metropolitan areas when it comes to IV drug use among heroin addicts. 
Because of injection drug use's attendant health issues--like 
hepatitis C, HIV and other infections that are spread through the use 
of dirty needles--studies have put the cost-benefit rat! io for 
treating IV-drug users higher than for other drug users--between $7 
and $12 saved for every $1 spent.

Jail is where Elon Burns learned how to shoot heroin. He had been 
smoking the drug since he was 13 and was convicted for drug 
possession when he was 19. With no access to syringes, inmates 
fashion makeshift shafts to inject drugs. It was from one of these 
shafts that Burns contracted hepatitis C.

After spending 11 years in and out of treatment programs and jail, 
Elon decided to give methadone a try. Gretchen Burns Bergman--Elon's 
mother--is the executive director of Parents for Addiction Treatment 
and Healing (PATH).

Bergman said she initially wasn't in favor of methadone treatment. 
Like many critics of medically assisted treatment, she saw it as 
simply replacing one drug with another. She knew her son was already 
using methadone to tide him over until he could buy more heroin.

"They say [addicts] have an epiphany somewhere along the line, and I 
think here he was in his early 30s knowing he had overdosed several 
times, knowing he'd been tossed aside by society behind bars, but 
also, as he's described to me, knowing that his family still loved 
him... so it was sort of like: Maybe I could try to use this 
methadone the right way. And just see if I could do it," Bergman said.

Elon's been clean for two years and works as a drug-treatment 
counselor in a medically assisted treatment program.

He's applying to graduate school, Bergman said. He's done well enough 
on methadone that he gets a 30-day take-home supply rather than 
having to show up daily for his dose. Bergman says Elon is able to 
function perfectly well on methadone but has talked about tapering 
off the drug or trying a newer form of narcotic-replacement drugs 
called Suboxone.

"I think there's that terrible fear--your life has balanced and it's 
good--of 'Oh my god, I don't want to rock the boat' type of 
mentality. Some people may want to be on [methadone] for the rest of 
their lives--that feeling of I never want to slip; I never want to go 
back and lose everything I've worked so long to regain in my life."

Bergman said that at drug-treatment conferences and statewide 
meetings she attends, she hears complaints about San Diego County's 
unwillingness to not only implement a methadone program, but also to 
be more progressive when it comes to treatment options.

"It's conservative San Diego" Bergman said. "Our Board of 
Supervisors, we have to fight on every level, even in terms of things 
that have been proven to really save lives, like needle-exchange programs.

"Sometimes when I go to these conferences with other cities, I listen 
to what San Francisco's doing, and I'm going, 'You guys are so with 
it, so understanding.'"

A number of people CityBeat spoke to for this story pointed to the 
county Board of Supervisors as the reason why methadone isn't part of 
any county programs. A spokesperson for Greg Cox, the board's current 
chairperson, said the supervisors have never taken an official 
position on methadone 9unlike needle exchange--a program where 
addicts can exchange dirty syringes for clean ones and get treatment 
referrals in the process. Supervisors passed a resolution against 
needle-exchange programs in 1997. The city of San Diego is the only 
city in the county that allows a needle-exchange program). The county 
used to fund methadone programs, but, like many other counties, cut 
funding in the late 1970s.

In a 2001 interview for a San Diego Magazine article on the rise in 
HIV infections in San Diego County, Supervisor Bill Horn, in response 
to questions about why the county doesn't fund methadone or 
needle-exchange programs, said his cousin died from a heroin overdose 
after a failed attempt at methadone treatment. Horn did not respond 
to requests for an interview.

Both Whitmyer and Peloquin have tried to meet with supervisors to see 
if they could change their minds.

"Dennis and myself have approached the county to say, 'Hey, why don't 
we have any of this treatment here?' Their response has been that the 
county Board of Supervisors disagrees with that treatment. 
Wonderful--let's talk to them. Let me educate them," Peloquin said.

"We have relationships with all the other counties within the state 
of California that [CRC is] in," Peloquin added. "We have the 
exclusive Prop. 36 and methadone treatment contracts in Riverside. We 
participate at some level in L.A. We're also participants in San 
Bernardino and Sacramento."

If the county's decision to not fund methadone treatment has been 
residents' loss, it's been CRC's gain. Where government isn't able to 
fill a need, the private sector picks up the slack. A 2005 study by 
the federal Substance Abuse and Mental Health Administration found 
that 54 percent of facilities that provide medically assisted drug 
treatment were run by private, for-profit entities while 35 percent 
were run by nonprofits and only 11 percent by federal, state or local 
governments.

Two years ago, CRC was purchased by Bain Capital (probably best known 
for its former CEO, Mitt Romney), and the infusion of cash has helped 
turn CRC into the largest drug-and-alcohol addiction treatment 
provider in the nation. Currently, CRC serves more clients than any 
other San Diego County drug-treatment provider.

Peloquin said it's not self-interest that's pushing him to advocate 
for medically assisted treatment. "If the Board of Supervisors say 
that they'll allow methadone treatment and CRC was not awarded the 
contract, I'm fine with that. As long as methadone treatment's being 
provided, that's fine."

Whitmyer, who ran drug-free treatment programs before moving over to 
CRC three-and-a-half years ago, sees it a little differently. He 
doesn't want to deal with county bureaucracy.

"What we want is acceptance of who we are and that we're here and 
they refer people to us. I want Prop. 36 money, by the way, but as 
far as county funding, it's too much to deal with them. But Prop. 36, 
we should be receiving funding for patients who qualify for Prop. 36."

Roughly 65 percent of clients pay for treatment out-of-pocket, 
Peloquin said, and the rest receive Drug Medi-Cal.

"if you're on meth, if you have an alcohol problem or a cocaine 
problem, the county will pay for your treatment, but if you have a 
heroin problem or an opiate problem, unless you're willing to go cold 
turkey in their social model programs, they won't pay," Whitmyer said.

CRC's largest facility is in Mission Valley, on Friars Road. From the 
building's south-facing windows you can see Nordstrom and the Fashion 
Valley Mall just across the street.

Sue Garrett is the program director at the Friars Road facility. 
Garrett's worked in the medically assisted treatment field for 20 
years and has seen it evolve from so-called "juice bars," where 
clients would come in, take their dose of methadone and be hit up by 
a drug dealer on their way out.

"We've cleaned up a lot of that; we don't tolerate any drug activity 
on the property at all or you're out of here. We've come a long way," 
she said. "Back then, the services we provided, it was pretty basic. 
We didn't have patient-appreciation day, we didn't have [group therapy]."

Garrett and "Kathy" (she asked that her real name not be used) are 
sitting at a table in the conference room of the two-story building, 
which CRC bought from a previous methadone-provider five years ago 
and, according to Peloquin, spent half a million dollars to remodel. 
Kathy, an upbeat 36-year-old with shoulder-length blonde-brown hair, 
just had her second baby a few months ago. She's been on methadone 
for nine years, during which time she's had two kids (methadone has 
no adverse effects on a fetus), earned a master's degree and bought a house.

When Kathy was 15, a boyfriend introduced her to heroin. When her 
parents found out she was using, they put her in a two-week detox 
program. She started using again in college, "here and there," she 
says, until she got into a bad accident. "I started having 
pain-control problems, and [heroin] was a great solution."

She tried 21-day medically assisted detox programs but kept going 
back to using. A well-paying job and friends who were willing to buy 
heroin for her in exchange for a share of the purchase meant she had 
a steady supply of the drug. She knew how much she needed to 
function, she said: "As long as I had it, I was fine. The only time 
there's a problem is when you don't have it, because then you start 
going through withdrawals and you're in a really bad place."

One evening, she arrived home to find cops in her house. A friend, 
also a heroin addict, who was staying with Kathy, had an outstanding 
warrant. The police found Kathy's stash and arrested her, too. Her 
mom happened to be with her when it all went down.

"I saw there was a path--I could see it in my friends; I could see it 
in everybody around me--that that was not going to be my first 
encounter [with the police] if I continued on that road."

Methadone, she said, helped her get her life in order--because she 
didn't have to combat withdrawal, she was able to focus on what she 
needed to do to stay clean, like move out of San Diego and up to 
North County and cut ties with everyone she associated with as an addict.

"It's not just about taking away drugs; it's about taking away all 
the outside factors that influence why you're using," she said.

In addition to the CRC program, Kathy regularly attends AA meetings. 
It's there that she finds the same kind of treatment philosophy that 
governs programs like drug court: A person on methadone or any other 
narcotic-replacement drug isn't truly drug-free. The way some 
abstinence-only adherents see it, folks like Kathy are cheating. 
"There's a faction that says, 'You don't get to take tokens; you're 
not clean.' Well, no, you're taking Prozac; you're taking this, that 
and whatever. How come you're putting me off in a separate group? I'm 
abstaining just as much as anyone else."

Mark Parrino, AATOD's executive director, says medically assisted 
drug treatment needs to be thought about in the same way as any other 
illness for which medication is available.

"You have to strip away for a moment moral impediments and moral 
questions, and you have to say, 'We're treating in illness; this 
patient has a disease,'" Parrino said. "The disease is chronic in 
nature; it needs medication and ongoing treatment--the way you treat 
hypertension, the way you treat diabetes, which means that the 
patient stabilizes only as long as the patient takes medication."

One analog that proponents of medically assisted treatment point to 
is depression: Some people recover from depression after a year or so 
on medication; others might relapse and could require medication 
indefinitely. Likewise, it's not unusual to find folks who overcome 
depression simply through therapy, no prescription necessary.

"There's a thousand roads up the mountain" is how John Richardson 
puts it. Richardson is the vice president of Mental Health 
Systems--an addiction and mental-health treatment provider the county 
contracts with for services--and he's president of the county's 
Alcohol and Drug Service Providers Association.

Richardson said ADSPA is in the process of drafting a letter to the 
county saying that the association, which comprises 34 agency 
members, is taking an official position in support of medically 
assisted treatment.

"There's varying degrees of support" for medically assisted treatment 
among ADSPA members, Richardson said; "however, it's a consensus of 
ADSPA to acknowledge medically assisted treatment as a viable 
treatment methodology.

"We're not advocating for funding; we're not advocating for the board 
to do something different," he said.

Mental Health Systems follows the drug-free, social-model of 
treatment and Richardson said he's seen heroin addicts get clean and 
stay clean under that kind of program. According to the county, the 
success rate for heroin addicts in the programs it contracts with is 
49.3 percent and for opiate addicts overall, 50.2 percent.

"It got a bad rap for many years because a lot of times the methadone 
clinics were considered juice bars," Richardson said, " and, quite 
frankly, they were. A lot of addicts abused the methadone system. 
However, a lot of people have gotten clean and sober and have recovered."

"I can supply numerous accounts as to why methadone maintenance is 
the best form of treatment for opiate addiction," Peloquin said. 
"Then it becomes a political issue and why that is I'm not sure.

"If I can get 15 or 20 minutes at the next county supervisors meeting 
to educate them on methadone treatment, then I will do that," 
Peloquin added, because at the end of the day, there's a lot of 
people in San Diego who aren't being treated for opiate abuse." 
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MAP posted-by: Richard Lake