METHADONE CLINICS OFFER HEROIN ADDICTS A WAY OUT

Lawmakers consider expanding treatment

HUDSON - Starting at 6 a.m. sharp, men and women begin filtering into
an nondescript gray building off Route 102.

The timing of their arrival is significant for two seemingly
incompatible reasons. First, they are en route to work and need to get
in and out quickly so they can arrive at their jobs on time. Second,
for the sake of public relations, they are not allowed to come more
than 15 minutes earlier, or to dally after they are done.

"I don't want to have a soup kitchen-type atmosphere here," said
Robert Potter, the director of the facility, which became the state's
first short-term outpatient methadone clinic when it opened, quietly,
last October.

It's an oxymoron endemic to his business - treating heroin addicts
trying to kick the habit - but it's one he knows he must straddle
carefully. "Don't use reason," he advised a visitor trying to
understand why middle-class people seeking treatment for drug
addiction should not arrive before 5:45 a.m.

New Hampshire is one of eight states where extended methadone
treatment for addicts is illegal. However that policy, shared by
states including North Dakota, Mississippi and Vermont, could change
in the coming months if a proposal to allow long-term treatment,
called methadone maintenance, passes the Legislature.

Sen. Katie Wheeler, a Durham Democrat, has sponsored the legislation.
She is hoping the issue will be looked at in a medical context, rather
than a political one. "There's a perception that we'll be soft on
crime if we do this, that these will be places for addicts to hang out
and sell the drug on the street," she said. "We don't have a very
grown-up, nonpolitical view of this issue."

Currently methadone, a narcotic similar to morphine, can be prescribed
in New Hampshire to patients with chronic pain. It also can be used
for up to six months of detoxification treatment for heroin addicts.
State law makes an exception for pregnant women, who can get methadone
treatment for the duration of their pregnancies. Since that program
began two years ago, 15 women in the Nashua area have participated,
and delivered healthy babies.

At a Senate hearing last week, lawmakers unanimously approved
Wheeler's two bills: one to allow the Hudson clinic to provide
extended methadone treatment until the state approves a more permanent
program; in the meantime, the other would set guidelines allowing
similar clinics to open on a two-year pilot basis.

That decision was excellent news for the estimated 400 New Hampshire
residents - and perhaps many more - who travel out of state every day
to get the dose of orange liquid that allows them to function.

Officially, clinics in Lawrence and Lowell, Mass., serve 70 and 26 New
Hampshire residents respectively. However a spokesman for the clinics
said real numbers might be close to double that, since many people
from New Hampshire give Massachusetts addresses in order to qualify
for that state's insurance, which covers the treatment. Between 15 and
20 New Hampshire residents travel daily to a clinic in Portland, Maine.

It is a population whose very commute is a testimony to the social
stigma that still cripples addiction treatment in New Hampshire.

"The people of New Hampshire have a great fear of treatment because
they haven't seen the faces," said Michael Greene, a spokesman for
Habit Management, which runs methadone clinics in Massachusetts. "The
faces of narcotic treatment could be the faces of every person in
their community, faces that are indistinguishable from their neighbors."

Lengthy detox

Potter's facility, Merrimack River Medical Services, can legally offer
a maximum of six months of treatment, but for addicts, often that is
not enough; Potter estimates it takes an average of between 18 months
and two years to successfully wean someone from the drug.

The purpose of his clinic, a for-profit business that charges patients
$100 a week, is to stabilize heroin users on the lowest dose of
methadone needed to keep them from going into withdrawal. Once
stabilized, patients are supposed to slowly decrease their dose until
they are free of narcotics. But some patients panic at the thought of
coming off the drug before they feel ready; some may have gone back to
work and fear their lives will fall apart if they move too quickly. In
some cases, the addict quits the program early, or begins using heroin
again and gets kicked out.

Potter estimated 75 percent of his current clients have tried some
other form of detoxification, including intensive programs lasting
less than a week, and counseling. However, alternatives are getting
harder and harder to come by here, as hospital after hospital have
closed their detox centers, for which they were unable to get
sufficient insurance coverage.

Because heroin can wreak permanent physiological damage, some addicts
will take methadone for the rest of their lives. "In the words of the
founders of (Alcoholics Anonymous), once a cucumber becomes a pickle,
it may be very hard for it to become a cucumber again," said John
Dalco, a physician who works part time at Merrimack River.

The New Hampshire Medical Society, various drug treatment specialists
and the state Department of Health and Human Services all are
advocating passage of the legislation. They point to 30 years of
evidence that says the treatment works: Not only can methadone help
addicts withdraw safely from, and stay off, heroin, but once patients
begin treatment, they are more likely to get their lives in order.
They get treatment for other health problems (not only HIV, hepatitis
and sexually transmitted diseases, but routine concerns like dentist
visits or a sore throat); they get counseling; they often begin working.

Since the treatment became widespread, deaths related to heroin use
have decreased significantly. "They don't get high, they don't get
stimulated, they get normal," said Dalco, who urged the committee last
week to lift the ban on methadone maintenance. "It's kind of hard to
keep a job if you have to travel 200 miles a day to get your medicine.
You wouldn't ask a diabetic to travel 200 miles to get insulin."

Middle-class junkies

As it is, Potter's clinic, poised to become the state's first
methadone maintenance treatment center if the bill passes, already
attracts clients who have to drive an hour and a half every day to get
their dose.

But most of his 50 patients, he says, have to drive only 15 or 20
minutes to get there. That fact disproves what Potter calls the first
myth associated with resistance to methadone clinics. "People will
say, 'We don't have a problem here, not in our town.' I beg to differ,
and I have the zip codes to prove it."

Most of Potter's clients work, and many are professionals. Some are in
college and others are in the medical and legal fields. Some own their
own businesses. Most arrive at the clinic, already outfitted as a
doctor's office when Merrimack River took it over, between 6 and 8
a.m. They check in at the front desk and then go down the hall for
their dose, which a nurse hands to them dissolved in a plastic cup,
and watches them drink. Such a routine visit takes roughly two minutes.

Methadone comes in pill form, but it is dispensed as a liquid so
patients cannot sneak it out of the clinic and hawk it on the street,
where it generally sells for $1 a milligram. The Hudson clinic,
liberally alarmed, keeps the pills in a safe; so strict are the rules
dictating its handling that visitors last week were not allowed in the
same room with the drug when it was removed from the safe.

Patients also undergo random urine tests to make sure methadone is the
only drug in their system. They periodically see counselors - and
medical doctors if necessary. The whole operation, decorated in shades
of gray and generic office art, feels more like a suburban dentist's
office than a magnet for junkies.

That's exactly the effect Potter is going for - why signs are posted
all over the waiting room urging clients not to drive more than 5 mph
in the parking lot, why patients face ejection from the program if
they break the terms of their treatment - which brings him to the
second myth about methadone clinics he would like to debunk: that they
bring crime to a neighborhood. Rather, statistics show that as
addicts' exchange heroin for methadone, street crimes such as
purse-snatchings and muggings decrease.

The third myth, one opponents of methadone maintenance commonly point
to, is that the treatment simply substitutes one addiction for
another. That Potter does not dispute, since methadone, a powerful
narcotic, is addictive. Its advantage, however, is that if used at a
proper dosage, it has no effect on motor or cognitive skills - in
other states, pilots and medical doctors are on it. In addition, the
amount of methadone a user takes need not change, while heroin users
need higher and higher doses to satisfy their cravings. Finally,
methadone is carefully produced and regulated, while heroin is subject
to the vagaries of the street.

Heroin use rising

Advocates of methadone maintenance treatment say there has never been
a better time to rethink the state's policy. Like states across the
country, New Hampshire has seen heroin use spike in the past four
years, particularly among middle-class teenagers. The state's Drug
Abuse Warning Network found that mentions of heroin use during
emergency room visits to hospitals had roughly doubled every year
between 1996 and1998. State statistics report that the drug has
replaced cocaine as the third most commonly used drug here, behind
alcohol and marijuana.

As heroin has become more accessible, it also has become cheaper - a
bag typically costs $6 to $10, and is good for about two hits. It also
is purer than ever before, making it more potent, and potentially more
dangerous. And while it mostly travels from Massachusetts and spreads
along New Hampshire's interstate highways - to Nashua and Manchester,
Portsmouth and Claremont, smaller cities and towns are not immune.

Gary Sobelson, who practices family medicine in Concord, has seen more
heroin cases in his office in the past two years than he has in the
previous 10. "These are high school kids who to you and me look like
the cheerleader," he said. Of his three recent heroin cases, one was
an adult (an engineer) and two were teenagers.

"Heroin is very common from about tenth grade on," said Gerard Hevern,
a family doctor in Allenstown who also has specialized in drug
treatment. "It is as readily accessible as beer in any of the high
schools locally, and throughout New Hampshire." Like Sobelson, his
patients include several heroin users.

While methadone maintenance is not the ideal treatment for all users -
especially for young people who have not been using long - Hevern said
it is a very successful method for some, "although governments and
society don't want to necessarily hear that." Drug addicts, too, are
ambivalent about the treatment, he added, just as many depressives are
reluctant to treat their illnesses chemically.

State health officials are so confident about methadone's positives
that they are lobbying to forgo a pilot program, as called for in
Wheeler's bill, and skip straight to a permanent program. That way,
clinics like Hudson's could soon be operating to capacity. As Rosemary
Shannon, chief of treatment services for the state's division of drug
abuse prevention, put it, "It's not the people in treatment you're
worried about, it's the people who aren't in treatment."