Road to recovery

Road to recovery

“Opium teaches only one thing, which is that aside from physical suffering, there is nothing real.” —André Malraux

 

The wild monster

The Toyota hatchback that Dwaine bought for $100 shuddered as it hit interstate speed. Smoke curled from the Marlboro between his fingers and slipped into the air rushing outside his window. In the cool morning, Dwaine could see mist rising like ghosts in the creekbeds along Interstate 81, just south of Harrisonburg.

   He wore a gray sweatshirt and black track pants, with a can of Mountain Dew balanced on the car seat between his legs. Despite the chill, beads of sweat glistened on his high forehead.

   “I’m feeling really anxious right now,” he said, aiming the car for the exit to I-64 East. “My medicine is down at the end of this road, and I’m feeling like I’ve got to get there.”

   The end of the road for Dwaine is the Addiction Recovery Systems (ARS) clinic on Pantops Mountain in Charlottesville. Since August, Dwaine has been receiving methadone at the clinic to treat a heroin addiction that gripped him for the past 20 years. For the better part of his life Dwaine has spent each day at the mercy of what he calls “the wild monster,” that part of himself that craves a heroin fix so fiercely that he would do anything—literally, anything—for just one more.

   Although he speaks frankly about his addiction, C-VILLE decided not to use Dwaine’s full name to protect him from the stigma associated with drug addicts.

   Now his fix is methadone, a synthetic opiate originally designed during World War II as a substitute for morphine. In clinics like ARS, methadone is administered as a treatment for heroin addiction, and, increasingly, opiate-based prescription pain pills, such as OxyContin. Those narcotics are classified by the Drug Enforcement Administration (DEA) as Schedule II, meaning they have been approved by the U.S. government for medical use, but they also have a high potential for abuse.

   Methadone is also a Schedule II narcotic. Because methadone is itself addictive and opiate-based, it remains a controversial treatment. At ARS, specialists provide controlled doses of methadone that curb cravings and stave off withdrawal without getting patients high. It’s the only thing that helps them live a “normal” life, many addicts say.

   Yet as methadone becomes a more popular treatment—not only for junkies but also for the growing number of people hooked on prescription pain medication—it is showing up more and more on the black market. As with any opiate, methadone’s line between pleasure and overdose is harrowingly thin.

   The controversy over methadone is just a small part of our cultural ambivalence about drugs and addiction. The same adults who tell kids to “just say no” also consume an ever-growing array of pharmaceuticals promising miracle cures for boredom, anxiety, gluttony or sexual indifference. We can’t seem to agree on whether addiction is a disease or a moral failing (or perhaps a bit of both). Should we try to help addicts or leave them to suffer the consequences of their choices?

   Dwaine, too, is conflicted about drugs. He has no doubt that methadone saved his life. Yet even as his car sped from Middletown toward Charlottesville on a recent Saturday, Dwaine felt that wild monster inside him, pulling on its chain. “I can’t drop my guard at any time,” he says.

 

Just like Jesus’ son

The opium poppy, Papaver somniferum L., is an annual herb native to southeastern Europe and western Asia. People have cultivated poppy as a drug, a medicine and a lucrative commodity since at least 3400 B.C., when the Sumerians of Mesopotamia referred to it as “hul gil,” or “the joy plant.”

   Today science reveals more about the poppy’s magical properties.

   In times of pain or stress the brain releases endorphins, a neurotransmitter that produces feelings of euphoria and relaxation. Chocolate releases endorphins, hence its reputation as a “comfort food.” After prolonged exercise, endorphins are believed to produce what’s known as a “runner’s high.” Sex, meditation, massage and acupuncture have all been shown to release endorphins.

   Chemicals in poppy plants—opiates—appeal to the same part of our brains as do endorphins. One to three weeks after a poppy plant flowers, an incision in the seed capsule causes the plant to secrete a milky latex. When this substance is collected and dried, it can be refined into opium, which today is further refined into three important substances: codeine, morphine and thebaine.

   Codeine is the most widely used natural pain reliever in the world, usually combined with aspirin or acetaminophen and taken orally. Thebaine is used to make oxycodone, the active ingredient of the brand-name drug OxyContin, manufactured by Purdue Pharma L.P. Morphine is perhaps the most effective pain reliever in the world, also the raw material for heroin. Heroin was widely used by physicians to treat pain between 1874 and 1914, until the Harrison Narcotic Act prohibited the highly addictive substance.

   Dwaine, now 41, discovered just how powerful heroin can be when he first started using the drug in his early 20s. He was living in Middletown, where he worked as a regional manager for Ford. His wife worked for the federal government, and together they were able to afford a house, a boat, a car, a motorcycle and a brand new son.

   Friends introduced Dwaine and his wife to cocaine and heroin. “It’s great,” says Dwaine, describing the feelings he got from a shot of heroin. Shooting or snorting drugs delivers a large dose of opiates quickly to the brain; this sudden rush of narcotic causes the high.

   “It feels warm, like your mother’s embrace. I had energy. I was outgoing. I could work for days at a time with no sleep,” he says. “It was like I was being nurtured by the drug.”

   In fact, it was just the opposite. Because even as heroin’s opiates make users feel, as Lou Reed famously put it, “just like Jesus’ son,” the drug slowly destroys the body’s ability to produce its own endorphins.

   Dwaine says it took only three days to get hooked on heroin. After that, his nose would start to run a few hours after his last fix. It was the first symptom of “dope sickness,” or heroin withdrawal.

   “It’s like a bad case of the flu,” he says. “You have diarrhea, you throw up, you can’t sleep, you break out in cold sweats. Your joints ache.”

   Because the body develops a tolerance for heroin, Dwaine found that as time passed it took more and more of the drug to get him high. The cost of his habit mounted to $250 per day; within 16 months of trying heroin, he had sold his house and all his possessions. His marriage dissolved. Dwaine’s ex-wife took their son. “I heard through the grapevine that she cleaned up from the heroin, but she developed a bad alcohol problem,” he says.

   Dwaine took a different route. He moved to Washington D.C., where heroin was readily available for about $10 a dose. He moved into an Amtrak train tunnel, a home for transient junkies known as a “shooting gallery.” His bed was an old mattress, his shower was a water pipe he busted open with a sledgehammer. Scoring the next fix was his life’s ambition.

   “Stealing, scamming, hustling, male prostitution… I’ve done it all, man.”

 

 Pain killers

In many ways Dwaine represents the archetypical methadone patient—the desperate, strung-out dope fiend. But according to Mary Lynn Mathre, executive director of the ARS clinic, the majority of methadone patients are addicted not to heroin, but legal painkillers prescribed by doctors.

   Other methadone clinics across Virginia have noticed the same trend. Ofelia Sellati runs five methadone clinics, each with about 120 patients, in Virginia and North Carolina under the name Sellati and Company. At her clinics in Richmond and Virginia Beach—urban areas where heroin is more prevalent—about 80 percent of clinic patients are heroin addicts. In suburban areas like Manassas, Sellati estimates that between 50 percent and 60 percent of clinic patients are addicted to prescription pain medication.

   “These are housewives, or your average citizens,” Sellati says.

   According to Paul Lombardo, director of the Program of Law and Medicine at UVA’s Center for Biomedical Ethics, a recent shift in medical culture has made doctors more willing to prescribe potentially addictive painkillers that contain opiate-based active ingredients.

   “In the past, the default position was to be very careful about giving addictive substances,” says Lombardo. In the past 20 years, though, Lombardo says, the experiences of terminally ill patients gave greater acceptance to opiate painkillers. “More recently the pendulum has swung the other way, toward being more proactive about relieving pain,” he says.

   As doctors became more liberal about prescribing synthetic opiate-based pills, also known as opioids, drug companies turned more aggressive in their marketing tactics.

   In 1995 Purdue Pharma L.P. introduced a form of the narcotic oxycodone called OxyContin. Whereas other opiate-based drugs usually came in 5-10mg tablets, Purdue introduced OxyContin in 10, 20, 40 and 80 mg tablets. In 2000, Purdue released a 160 mg tablet that has since been discontinued.

   When taken orally, OxyContin is time-released—the drug seeps slowly into the body and the effects last for 12 hours. Its pain-relieving power was a godsend for patients with severe, chronic pain, but also a temptation to people in search of a high. OxyContin’s time-release property is lost when creative abusers crush up the pills and either snort or inject them. Then the opiates flood the brain suddenly, producing a high.

   When patients discovered they could make money selling their pills, police in the rural Southeast began to notice that a growing number of crimes were associated with addiction to OxyContin, which became known as “hillbilly heroin.” Middle- and upper-class drug addicts (most notably conservative talk radio host Rush Limbaugh) also found the rush of OxyContin hard to resist.

   According to the 2003 book Painkiller by New York Times reporter Barry Meier, in 2001 Purdue spent $200 million in an aggressive marketing campaign that encouraged general practitioner doctors to prescribe OxyContin to people with less-than-severe pain, while suppressing evidence that the drug was addictive and that people were dying from overdoses.

   The pharmaceutical industry has countered that the actual number of deaths directly attributable to OxyContin overdose is unknown, and that reports of an OxyContin abuse epidemic are greatly exaggerated. Regardless, the controversy isn’t hurting Purdue—in 2002 doctors wrote
7 million prescriptions for OxyContin, a windfall of about $1.5 billion, according to a group called Relatives Against Purdue Pharma (a group pushing the FDA to toughen its guidelines regarding OxyContin). Purdue is now seeking FDA approval for an even stronger opioid, Palladone.

   Whether the abuse of opioids can be rightly called an “epidemic,” police say they’ve seen an increase in the number of prescription pills trafficked on the black market. In response, the State Department of Health monitors all Schedule II narcotics. If a doctor is prescribing an unusual number of Schedule II drugs, the Health Department will investigate and share information with the Virginia State Police, which in the past six years has expanded the number of officers who investigate prescription pill abuse.

   “The physician is in an almost impossible position,” says biomedical ethics expert Lombardo. “They have patients clamoring for the latest drugs, but they’ve got the government looking over their shoulder.”

   In April, William Eliot Hurwitz of McLean was sentenced to 25 years in jail and a fine of $1 million for illegally prescribing oxycodone after federal investigators discovered he had prescribed some patients a monthly supply of, in some cases, 1,600 pills of OxyContin and other drugs per day, according to the DEA.

   “A lot of people have real pain, and they’re scared that if they lose their pain medication they’ll have nothing,” says Dr. Robin Hamill-Ruth, director of UVA’s Pain Management Clinic. Doctors refer pain patients to her clinic, and she estimates that about one in 10 are addicts looking for drugs. The clinic keeps careful records of their prescriptions, and she recommends suspected addicts to a program to wean them off the drugs, or to the ARS clinic. “If they’re doing something grossly illegal, I have no qualms calling the cops,” says Hamill-Ruth. “If we’re not consistent about enforcing our opiate agreements, we’re setting ourselves up to be investigated by the feds, and you’re setting up patients to lose their medication.”

 

Heroin for the housewife

An ARS patient named Linda (not her real name) describes how the monster of addiction can sneak up on a typical “soccer mom.” Linda is now 40. In the early 1990s, she and her family lived in a small town in southwest Virginia. During a series of dental surgeries over the course of two or three years, her doctor prescribed Percocet, a combination of oxycodone and acetaminophen, to ease the pain.

   “I liked it immediately,” says Linda, who says Percocet “made me feel better and gave me a lot more energy. It progressed pretty rapidly to the point where I was going to dentists and doctors all the time trying to get medication.”

   Linda went to various doctors and dentists, asking for new Percocet prescriptions. When one doctor got suspicious that she might be an addict, she would go find a new one.

   “I would lie,” Linda says. “I was totally scamming them to get what I want.”

   When she couldn’t trick a doctor, Linda says, she would raid her friends’ medicine cabinets and steal whatever opiate-based pills she could find. “Nobody knew what I was doing. It was shameful,” she says. “I used to pray to God at night to help me.”

   Help came in the unexpected form of the law, when a family friend caught Linda stealing pills and turned her into the police. Linda went on probation and entered rehab. Quitting Percocet produced the same withdrawal symptoms Dwaine knew all too well. She drank and took diet pills to get high, and soon returned to opiate-based drugs.

   She started seeing a therapist, who explained quitting Percocet was so hard because the drug had changed her brain chemistry. Linda read about opiate addiction, and discovered methadone.

   She asked her family doctor about meth-adone, and encountered what many addicts say is a common response to their condition. “The doctor treated me like I was the biggest scum on the face of the earth,” says Linda. “He said I needed to go apologize for my sins and stop taking drugs. I was just shamed.”

   Linda found a clinic in Richmond, and started driving 75 miles each day to get a dose of methadone. “From the first day I dosed, everything was better,” she says. “I stopped craving drugs, I didn’t want alcohol. I didn’t want anything. It was absolutely amazing.”

   She has been taking methadone for six years. “I have no desire to go off of it,” she says. “The 12-step programs, I know they work for some people. But I’d rather be taking care of my children than going to meetings every day.”

   Talking about addiction with her children “is a really hard subject,” she says. Her 12-year-old son has asked Linda if she ever took drugs. “I’m not ready to tell him that,” she says. “We have lots of talks about genetics and alcoholism. I tell him that he is prone to addiction.

   “I hope I didn’t damage them much when they were little.”

 

To hell and back

While Linda nurtured her addiction in secret, behind the veneer of a typical wife and mother, Dwaine’s family—including his five children—harbor no illusions about his life. Dwaine now hopes his story will serve as a warning to his children and others about what can happen when that wild monster that may sleep within each of us wakes up and breaks his chain. Indeed, Dwaine’s tale of life among big-city junkies could be the most effective anti-drug message you’ll ever hear.

   He carries the scars of the devotion to heroin that landed him in that D.C. Amtrak tunnel.

   “Each of my arms probably has a couple hundred holes in it,” he says, rolling up the sleeve of his sweatshirt to reveal the veins in his forearm, which are now stained brown. To find a vein not destroyed by injections, he’s had to shoot heroin into every part of his body.

   “I’ve shot heroin in my dick I don’t know how many times,” he says. “I’ve been so constipated from heroin I’ve had to pull the shit out of my own ass. I’ve been there, man.”

   Dwaine has been shot at and stabbed with a screwdriver while trying to buy heroin in crime-ridden neighborhoods. He’s seen a drug dealer shoot a fellow junkie to death at point-blank range over $6. One morning Dwaine went to go buy coffee and doughnuts; while he was gone, someone shot his friend in the back of the head. Dwaine returned to the Amtrak tunnel to find his friend’s brains spilling out on the railroad tracks.

   Heroin is most deadly when addicts are struggling to get free of it. One of Dwaine’s close friends from the shooting gallery, Ronnie, kicked the drug for several months. When he succumbed to his cravings again, Ronnie made a mistake that almost invariably leads to an overdose.

   During peak usage, addicts build up a high tolerance to heroin. When they quit, their tolerance declines; but when they return for that one last fix, they often use the same potent dose of heroin as when they were active users. That’s what caused the overdose that killed Ronnie, a father of twin daughters. “He blue-lipped on me,” says Dwaine. “I gave him CPR, and he died in my arms.”

   Dwaine’s stint in the shooting gallery finally came to an end after a failed robbery attempt. He and a friend were trying to steal tools out of a pickup truck when the owner caught them. Dwaine’s buddy jumped in the car and turned the engine as Dwaine dove headfirst into the front seat. The driver tore across the parking lot as Dwaine hung on for dear life, his legs dragging across the asphalt. The friction tore Dwaine’s kneecap off his leg, but instead of going to the hospital he reattached his kneecap with duct tape and returned to the shooting gallery. His friends left him to fend for himself, and after two weeks Dwaine finally called his parents and begged them to rescue him.

When they finally took him to the hospital, doctors discovered his wounds were infected with gangrene.

   Dwaine spent the next several years in and out of his parents’ house in Middletown, couch-surfing between Culpeper and Fredericksburg, always making trips to Washington D.C., to keep himself supplied with heroin. He says he lost a total of five houses to his addiction, and he spent 11 days in a coma after trying to kill himself with an overdose.

   After he caught hepatitis from a friend while sharing a heroin cooker in Win-chester, Dwaine recalls lying in a hospital bed following chemotherapy treatments. His friends were sneaking syringes into the hospital so he could crush up his pain pills and shoot them. “Something just clicked. I knew at that point I didn’t want to be a drug addict. I had to do something.”

   Dwaine says he probably owes his life to his current girlfriend, who moved him away from Middletown and his old friends. He enrolled in the ARS clinic in August, and now he pays $500 a month for methadone treatments. He collects disability payments and works part-time as a carpenter.

   Keeping his monster chained is a daily struggle for Dwaine, as is living with the regrets for the damage caused by the monster unleashed.

   “How many friends did I get started?” Dwaine says. “One of them I feel really bad about. He’s strung out, he won’t work. He’s stealing stuff from his grandma and his mom and dad. I feel bad about that. I cleaned out my sons’ bank accounts when they were kids… that makes me feel like a real piece of shit.”

   Dwaine often takes his sons to the Smithsonian Museum in Washington, D.C., and the highway takes them right past the tunnel where Dwaine spent several years of his life. “It brings back a lot of memories,” he says.

 

Time will tell

Dwaine stopped his car in the parking lot of the ARS clinic, a nondescript brick building on Pantops. He makes a beeline past a small sign reading “Pantops Clinic” and enters a room with fluorescent lights, gray carpet and inspirational clippings tacked to a bulletin board.

   Non-patients who enter the waiting room must sign a confidentiality agreement, and a receptionist calls patients by a number, not their name. Dwaine says he’s usually in and out of the clinic in about 10 minutes, but there was a line on a recent Saturday, so the wait was longer. The tension in the room was palpable—fingers drummed, addicts paced and wondered aloud, “What’s taking so long?”

   New clinic patients can only be admitted when they’re in a state of opiate withdrawal, so that ARS clinical director Diane Oehl can tell they are truly addicted. “The first dose we give them is very low,” Oehl says. “They won’t feel great, but they’ll feel better.”

   Methadone has a half-life of between 24 and 36 hours, meaning it takes up to a day and a half for the body to process half a dose. This makes methadone a good treatment for addicts, because one dose of methadone will deliver opiates to the brain all day long, staving off cravings and withdrawal symptoms without producing a “high.”

   The long half-life, however, also makes methadone a dangerous drug. A person who buys methadone off the street may take multiple doses, trying to get high, even as the concentration of the drug builds in their bloodstream. “Hours later, you can fall asleep and never wake up,” says Mathre, the clinic’s executive director.

   In the first phase of treatment, Mathre says patients must come to the clinic every day to get their dose of methadone. Nurses gradually increase the dose until patients get enough to “achieve normalcy,” says Mathre.

   “Patients report feeling normal after a week,” says Mathre. “That’s the word they use: normal. Being able to get to a job, to function as a student or a parent. That’s our goal.”

   Methadone clinics are strictly regulated by the DEA. If patients satisfy a list of eight criteria, including regular counseling, good behavior and clean urine tests, patients are allowed to take home a 30-day supply of methadone in small metal lockboxes.

   Dwaine emerges from a dosing room with a new supply of methadone, 130mg doses of red liquid that would kill a normal person—hence the metal security boxes. It takes about 30 minutes for the methadone to take effect, but Dwaine already looks more relaxed. “Sometimes when I’m coming down here, I’m worried that my medicine won’t be here,” he says. “Just knowing that I have it, now I feel better.”

   The monster sleeps, for now at least.

 

The straight dope on methadone

A safe treatment, a dangerous high

 Contrary to myth, methadone was not developed on orders from Adolf Hitler, although it was created in a German laboratory during World War II. During an epidemic of heroin abuse in New York in the 1960s, doctors first discovered methadone’s usefulness in treating narcotic addiction.

   Following the discovery, the media heralded methadone as a medical breakthrough. But the enthusiasm was tempered when doctors found that it was difficult to then get the patients to stop using methadone.

   Methadone does not “cure” addiction. “Very few medicines cure anything,” says Mary Lynn Mathre, director of the ARS Clinic on Pantops. “They treat chronic conditions.”

   Mathre acknowledges that meth-adone patients basically trade an addiction to heroin or painkillers for an addiction to methadone. In practical terms, Mathre and many methadone patients believe it’s a deal worth making.

   When administered by trained addiction specialists, a methadone dose is so low (usually starting around 80mg and slowly increased based on the patient’s level of addiction) that patients do not feel the pleasant sensations or euphoria associated with a narcotic “high.” A clinical dose of methadone simply relieves the physiological cravings by delivering a low dose of opiates over a 24- to 36-hour period. Methadone patients generally dose in the morning, and go all day without cravings, whereas heroin addicts start to feel withdrawal after four or six hours.

   Methadone patients, then, can spend the rest of their day doing something besides tracking down another heroin fix. Methadone is also less physically damaging than heroin, and it is even safe for pregnant women. While on methadone, patients experience the full range of emotions and physical sensations; their moods are normal, as are their reaction times and intellectual functions. The most common side effects of methadone are constipation, water retention, drowsiness, skin rash, excessive sweating and reported change in sexual drive.

   Like any opiate, methadone can be abused, and clinics must submit to a slew of federal regulations aimed to dissuade patients from selling their methadone on the black market. As a street narcotic, methadone’s time-release properties make it a dangerous high. Because methadone works slowly and lasts a long time, abusers can easily overdose, falling asleep and dying before they start to feel high.—J.B.

 

Source: U.S. Department of Health and Human Services, Substance Abuse and Mental health Services Administration. www.samhsa.gov.

 

Methadone’s method
The Pantops Clinic has withstood numerous State violations

While working as medical director for the First Step addiction clinic on Pantops, Dorothy Tompkins saw people who could not kick heroin and OxyContin. “It was really a tragedy,” says Tompkins. “I saw young people becoming suicidal when they couldn’t get off opiates.”

   So Tompkins began investigating methadone, and in June 2002 she invested her own money to open the nonprofit Pantops Clinic. It was the first place in Charlottesville to distribute methadone, an endeavor that—as Tompkins would discover—is subject to strict scrutiny from State and federal regulators.

   In the almost two years that Tompkins ran the clinic, a State agency recorded 160 violations. Most of the violations involved the clinic’s failure to document its work according to State rules, but in early 2004 the Virginia Department of Mental Health, Mental Retardation and Substance Abuse Services investigated two more serious complaints against the clinic.

   According to State documents, a 2003 investigation found that the clinic’s pharmacy didn’t meet federal security regulations, “with the pharmacy safe remaining unlocked throughout [the investigator’s] visit.”

   In February 2004, there were two additional investigations. The first “found that multiple individuals have been provided with excessive numbers of take-home medications, sometimes without assessment.” The second investigation involved two incidents indirectly linked to the Pantops clinic. In one case, a person was found dead of methadone overdose, along with a bottle of methadone that had been dispensed for a client of the clinic. “Diversion of methadone from clinic clients is of concern given the lack of adequate assessment for take-home medications that were found to be occurring,” according to a March 2 letter from the department to Tompkins.

   The department allowed Tompkins to sell the clinic, which she did in April 2004, to a Pennsylvania company called Addiction Recovery Services. “The previous owners were a nonprofit group, and I think they underestimated the amount and the intensity of the regulatory scrutiny,” says Jeff Kegley, president of ARS. “They tried to operate it as a physician practice, and it just doesn’t work that way.”

   Clinics must be licensed and inspected by State and federal agencies, and by one of three private accreditation companies. As the only administrator for the clinic, Tompkins agrees she was overwhelmed by the “tremendous task” of managing the bureaucracy. In April, the Virginia Board of Medicine slapped Tompkins with a $4,000 fine for the numerous violations.

   Kegley now runs the clinic as a for-profit operation. Most of the income is from the $80 fee patients pay each week, for which in return they receive methadone, lab tests and the counseling that the law requires as a part of methadone treatment. There are currently about 125 clients at the Pantops clinic. “Like any other business, we expect to be able to make a living,” says Kegley. “But the economics are pretty small. You have to love the work.”—J.B.

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