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."