DETOX DEBATE RAPID DRUG WITHDRAWAL METHOD DRAWING CRITICISM

A medical procedure allowing drug addicts to be detoxified within hours has
been making the rounds on America's TV screens. It's also creating
controversy in medical circles nationwide.

In last season's tense closer for the television drama "ER," Dr. Doug Ross
performed the procedure on a baby born addicted to drugs. Rapid detox also
figured in the script of the soap opera "General Hospital," helping rid Dr.
Alan Quartermaine of his year-and-a-half-long drug habit.

This treatment is targeted at patients who are addicted to painkillers like
morphine and Demerol or opiates like heroin, methadone and opium. During the
procedure, a patient is placed under general anesthesia for four to six
hours. While unconscious, he or she receives an intravenous dose of what is
called a narcotic antagonist, which helps remove heroin and other opiates
from the brain, sending the patient into withdrawal. Using this treatment,
patients avoid acute withdrawal symptoms - often several days of
increasingly agonizing chills, nausea, vomiting, stomach cramps, diarrhea
and a crawling feeling on the skin - that are frequently associated with
going "cold turkey." While patients may experience some withdrawal symptoms
after the procedure, the more intense symptoms peak while the patient is
under anesthesia.

Typically, doctors performing this treatment require patients to follow up
with psychological support provided by a mental health professional or
narcotics support group. Patients are also placed on the nonaddictive drug
naltrexone for up to a year. Naltrexone reduces the craving for drugs and
blocks their effect should a person begin using drugs again.

But even as the quick detox procedure gains popularity in this country and
abroad, critics allege its drawbacks far outweigh its pluses. Some cite the
risk of death - however small - that can result from the general anesthesia
used for the procedure. Others say more research is needed to validate
claims of its effectiveness. Still others contend that longtime addicts are
better off with conventional maintenance programs, which distribute daily or
near-daily doses of methadone. They say methadone - the longer-acting
substitute for heroin and other opiates - helps stabilize addicts' lives.

Dr. Wesley Sowers, medical director for Addiction Services at St. Francis
Health System, said his department has looked at the rapid procedure, but
does not offer it at this point. "It's relatively new, even though it has
some promising initial results, it's not clear it's superior to other
methods of detox," he said.

He noted the risks of anesthesia and extra costs as among the reasons why
St. Francis doesn't offer the procedure. "You expose people to certain risks
just by putting them under anesthesia....It's not clear at this point that
that's a risk worth taking."

Sowers said he believed rapid detox is best reserved for folks who have not
had success detoxing in other ways. The key issue in successful recovery,
however, is staying in treatment after detox, he said. "We detox people all
the time. It's not the most pleasant thing in the world. Once they get
through it, they need to make lifestyle changes needed to make recovery."

The rapid detox procedure has its roots in therapies established in Israel a
decade ago. The treatment was then introduced in Europe, Mexico and Puerto
Rico, and in 1996, the CITA investment group brought the procedure, called
"Ultra Rapid Opiate Detoxification," to the United States, patenting it
under the label UROD. (UROD is currently performed at hospitals in New
Jersey, Los Angeles, Miami Beach and Chicago.)

Dr. David Simon, an anesthesiologist, offers a similar detox procedure,
which he calls "Intensive Narcotic Detoxification," at his facility, the
Nutmeg Intensive Rehabilitation Center in Tolland, Conn.

Simon charges $3,400 for his procedure. He says it's considerably more
cost-effective than a typical methadone program - which may run as much as
$6,000 annually and continue indefinitely. Simon says that while methadone
programs are covered by Medicaid, his quick detox isn't. Nor, he adds, is it
covered by most medical insurance plans.

Adversaries of the detox method insist there's more to it than meets the
eye.

The procedure "involves using anesthesia, and even though they claim the
risk is low, there is always some risk associated with using anesthesia that
you don't have in using conventional methods of detoxification," says Dr.
Richard Frances, medical director and chief executive officer of Silver Hill
Hospital, a New Canaan, Conn., substance abuse treatment center.

Frances also says that because veteran addicts are unlikely to follow up
with psychological support as required of quick detox patients, there's an
increased possibility of backsliding. "There may be a danger that after the
very rapid detoxification, some of these people will take larger doses and
overdose," he says. "You can have {recidivism} with any kind of detox, but
if there is not adequate rehabilitation, this could be an issue."

Opponents of the procedure, such as Dr. Frank Vocci, director of the
Medications Development Division at the National Institute on Drug Abuse in
Rockville, Md., believe the treatment requires more research. Because it's a
procedure rather than a drug, Vocci says, there's no need for a federal
regulatory body to give it a stamp of approval. And that's the problem, he
says.

"I don't know what it is that people want us to show that we haven't as yet
shown by experience," Simon responds, noting that the procedure has been
performed on thousands of patients in the United States.

"There's no reason why we have to test anesthesia," he says. "The only thing
here is that anesthesia is being administered to treat heroin addicts, and
we know how safe it is."

Dr. Clifford Gevirtz, clinical director of anesthesiology at New York City's
Metropolitan Hospital Center, performed UROD at the facility until last
September. The program was terminated because of a contractual issue with
the holders of the procedure's patent. Still, Gevirtz gives the procedure
high grades because of its cost- effectiveness and significant success rate.

He reports that after one year of follow-up, 51 percent of the 184 patients
in the program remain drug-free. Gevirtz also cites the therapy's
humaneness. "I don't think {patients} need to experience a great deal of
pain and agony," he says. "We can avoid that."

Gevirtz addresses critics like Silver Hill's Frances, who believe that
opiate-free alternatives are not for everyone. Frances says while the
procedure may be effective for young people or professionals extremely
motivated to end their drug addiction, he thinks hard-core street addicts
are better off on methadone maintenance because they'd be more inclined to
relapse to drug usage after a quick detox.

Of the 300 patients who have undergone this procedure in Simon's facility
over the past two years, 25 percent have dropped out four months after
treatment, Simon reports. He compares this to high dropout rates from other
treatments like methadone. A 1991 study conducted by John C. Ball and Alan
Ross, authors of "The Effectiveness of Methadone Maintenance Treatment:
Patients, Programs, Services and Outcome" (Springer Verlag), reported that
people on methadone have a nearly 58 percent recidivism rate after four to
six months. After 10 to 12 months, the dropout rate increases to 82 percent.
Simon says conventional detox procedures require addicts to return over
several days to get increasingly larger doses of naltrexone and other drugs.
Dropout rates are high as a result because withdrawal symptoms get
progressively worse before they improve.

"Through our program, they don't drop out once you put them to sleep," Simon
says. "Without question," he adds, the quick detox "is the most
compassionate detoxification procedure there is."