TREATMENT: NEW WAYS TO STAY CLEAN

Beating An Addiction Is Tough, But Scientists Are Creating An Arsenal
Of Weapons, From Pills And Vaccines To Innovative Counseling

Getting Help: A Substance-Abuse Treatment Program At The Phoenix House

Feb. 12 issue - When Colin Martinez turned 43 a couple of years ago he was
living under a bridge in Denver. By his count, he had devoted 31 years to
getting wasted. "I smoked crack or freebased for 16 years," he says. "I
injected heroin, injected cocaine, snorted cocaine and heroin, popped
pills, smoked opium, smoked pot and hashish. I took anything-a lot of it on
the same day." He worked off and on after quitting high school in the '70s.
He also married and had several kids. But addictions crowded everything
else out of his life. He stole from employers to keep himself in drugs. He
skipped out on his family for weeks a time. And despite countless trips
through detox, he never really got clean. "If they were hassling me about
cocaine," he says, "I'd do something else instead." When he awoke one
morning to find his buddy's cold corpse beside him, he knew he was
approaching the same end.

Things couldn't be more different today. In a last-ditch rescue effort,
Martinez's father sent him to the Caribbean island of St. Kitts two years
ago to take part in an experimental [ibogaine]-treatment program. This
time, Martinez didn't return to his old haunts as soon as his urine was
clean. He moved to Florida to join a community of other recovering addicts.
And with that support in place he has managed, for the first time since the
age of 12, to stay free of drugs. Instead of peddling stolen car keys, he
now works as a staff assistant at the University of Miami. "I have friends
and a job, and I like who I am," he says. "I never thought I'd even be able
to flip hamburgers again, but I'm doing purchasing and handling accounts."
He is also communicating with his children. "My life has been a mess," he
allows, "but today it's pretty cool."

THE RISK OF RELAPSE

Overcoming addiction is never simple. The risk of relapse is so high-
roughly half of all patients fall off the wagon within a year of
detoxification -that many health-care professionals consider treatment a
waste of time. When researchers at California's Kaiser Permanente health
plan surveyed doctors and nurses a few years ago, most viewed medical
intervention as "ineffective" and "inappropriate." The truth is not so
grim. Addiction may never be as treatable as strep. But with medication and
intensive, long-term support, even the most inveterate abuser can succeed.

Drug dependency is less a failure of will than a miscarriage of brain
chemistry. Substances like cocaine and heroin don't simply feel good; they
reconfigure the reward system that makes things feel good. By releasing the
chemical messenger dopamine at critical moments, our neurons reward
survival-enhancing activities, such as eating and lovemaking, and give us
strong incentives to repeat them. Addictive substances artificially boost
dopamine's effects. And as we adapt to their pleasures, the quieter state
that once felt normal begins to feel like blight. The recovering addict's
challenge is to live with that sensation.

For people hooked on heroin and other opiates, medication can make getting
clean a lot easier. Morphine and its cousins, including heroin, all work by
docking with a cell receptor called mu . By stimulating this receptor, they
slow the transmission of pain signals within the brain, while increasing
the release of dopamine. Methadone, the most widely used medication for
heroin addiction, works by a similar mechanism. But because it is taken up
more slowly, it produces a much milder sensation. Unlike heroin, methadone
can be taken orally, and its effects last 24 hours instead of four. By
downing a cup of powdered solution each morning, an addict can ward off
withdrawal without having to shoot up, deal with pushers or walk around
looking drugged. The regimen substitutes one form of dependence for
another, but addicts in methadone programs are more likely to have jobs,
less likely to commit crimes and less prone to HIV infection.

Unfortunately, most of the people who could benefit from methadone don't
receive it. To guard against abuse and overdose, the federal government
restricts the drug to specially licensed clinics that please no one. Few
recovering addicts are comfortable parading in and out of these clinics,
and no neighborhood wants to house one. Eight states have no methadone
clinics at all. The only alternative medication is naltrexone (Revia),
which is available by prescription but even less popular among addicts.
Naltrexone works like a chastity belt, sealing off the mu receptor to make
it inaccessible to heroin. The drug will send an untreated addict directly
into withdrawal (not a good idea), but it can help a clean addict stay that
way. It's used mainly by "lawyers, physicians and business executives,"
says Columbia University psychiatrist Herbert Kleber-" people who have good
jobs and risk losing them if they relapse."

TICKLING THE RECEPTORS

In the near future, heroin addicts may have a third alternative. The new
drug-buprenorphine-acts like extra-mild methadone at low doses, tickling
the mu receptor to create a barely perceptible buzz. But unlike methadone,
it's neither intoxicating nor dangerous at high doses. If a user takes more
than the prescribed amount, it jams the receptor, diminishing the high
instead of exaggerating it. Reckitt Benckiser Pharmaceuticals of Richmond,
Va., has applied to market buprenorphine as an under-the-tongue lozenge
called Suboxone, and federal approval is expected soon. Because doctors
will prescribe it directly, experts say it may double the number of heroin
addicts receiving treatment.

Cocaine and methamphetamine pose a knottier problem. They, too, hijack the
body's reward system, making sobriety feel like purgatory-and there is not
yet a pill to ease that trauma. Counseling, therapy and training may not
ease the pain as readily as medication, but these interventions can be
powerful. "Addiction affects every aspect of an individual's interaction
with the world," says Dr. Alan Leshner, director of the National Institute
on Drug Abuse (NIDA). "People in recovery need to know how to control their
behavior, how to function in their families, how to go back to work."

Many clinics employ variations of the traditional 12-step program, which
centers on admitting one's powerlessness and seeking divine guidance. But
most also take concrete steps to change people's responses to their
environments. One approach, known as contingency management, uses rewards
to keep recovering addicts on track. At Johns Hopkins University, for
example, researchers have created a "therapeutic workplace" where
participants earn vouchers for rent and food by working as data-entry
operators. Their wages rise as their skills increase, but they lose
earnings if they fail a urine test or behave unprofessionally. Without the
monetary incentive, says Dr. Frank Vocci of NIDA, patients might rightly
believe they had little to lose. Given a chance to get high, "they would
ask themselves, 'Why not?' " he says. "Now they have an answer."

Will cocaine users ever have their own version of methadone, naltrexone or
buprenorphine? Researchers have tried for years to create a cocaine
blocker, but with little success. Unlike the opiates, which directly
stimulate a receptor, cocaine works by blocking the receptor that neurons
use to reabsorb dopamine after they release it. As Dr. Donald Landry of
Columbia University observes, it's hard to make a drug that blocks a
blocker. If you seal off its target, you've simply reinvented the drug. But
researchers are now pursuing a new approach. Instead of blocking cocaine's
target, they're exploring ways to neutralize the cocaine molecule itself,
whenever it enters the bloodstream. At Yale, for example, researchers have
started tests on a vaccine that may block the drug's effects for six months
at a time. With luck, it could reach the market by 2004.

ONE-SHOT CURE?

One way or another, the arsenal against addiction is sure to expand.
Leshner, of NIDA, estimates that 60 drugs are now under study as treatments
for cocaine addiction. One of the most controversial, a botanical called
ibogaine, may help alleviate a broad range of dependencies. This natural
hallucinogen is illegal in the United States, but University of Miami
neuro-pharmacologist Deborah Mash has spent five years studying it at the
Healing Visions Institute for Addiction Recovery in St. Kitts. Patients
take it just once, and many say it not only masks withdrawal symptoms but
gives them new perspective on their lives. "It doesn't work for everyone,"
Mash says, "but for detox from opiates it's a slam dunk." According to
Mash, cocaine users benefit, too, though less dramatically. So do
alcoholics. Critics say the evidence is only anecdotal, but ibogaine is the
treatment that started Colin Martinez on his current two-year rally.

Even when it works, medication is only one step toward recovery. Beating
addiction requires every tool on the table-medication, counseling, social
support, family support-and keeping up the fight when you're losing. As
Martinez has learned, treatment isn't a war but a long, slow siege.