A QUICK, CONTROVERSIAL THERAPY

Procedure gets results, but are patients at risk?

[PHOTO CAPTION] Above, Robert Sniras Jr. looks at a syringe containing a
pellet that will help him fight his heroin addiction. Below, Dr. Lance L.
Gooberman prepares a patient for his heroin detoxification method. Photo
by Chris Pedota

MERCHANTVILLE -- By her 30th birthday, Jennifer had open sores up and down
her arms and was shooting heroin into the veins of her feet. In seven
years, she'd been on and off methadone and in and out of rehabilitation
centers, but she had never gone a full month without getting high.

"I was in a living hell," said the Absecon waitress.

So, she took a chance July 7, the day after her birthday, on a
controversial medical procedure called ultra rapid opiate detoxification.
At his center in Camden County, Dr. Lance L. Gooberman anesthetized and
paralyzed his patient for four to six hours and administered heroin
blocking drugs called opiate antagonists to speed up withdrawal. While
Jennifer was unconscious, the worst of withdrawal occurred.

"If they were awake, they'd be flip-flopping like fish," Gooberman said.

Critics question the safety of the procedure, citing particularly the risks
of general anesthesia, and the state Board of Medical Examiners is
considering a ban except in a medical school or research institution.

Gooberman does caution that rapid detoxification isn't a painless quick
fix. Patients still feel symptoms, such as nausea, diarrhea, insomnia and
muscle aches, but the intensity is nothing like going cold turkey for two
to five days.

About 20 minutes into the procedure, Gooberman implants a pellet containing
a drug called naltrexone under the patient's skin near the belt or bikini
line. Small doses of the drug are released over two months and blocks
heroin from attaching to brain receptors, preventing a heroin high.

Addicts' bodies must be cleansed of heroin before taking naltrexone or they
will feel immediate and severe withdrawal -- thus the necessity of rapid
detoxification.

Jennifer tried to get high after the pellet was implanted but nothing
happened. "It's like banging your head up against a wall. You try to get
high but you don't feel it," she said.

Gooberman is the only New Jersey doctor who performs the procedure and
recently got a patent on the naltrexone implant so no other doctor can use
it without his consent. The procedure costs between $3,200 and $3,900 and
follow-up visits for replacement pellets cost $375 each. (A dozen medical
centers around the world perform rapid detoxification but give naltrexone
orally.)

No insurance company covers any part of the rapid detoxification treatment
because it's considered experimental. Meanwhile, Gooberman said since 1995,
1,800 patients have left his office drug-free.

"I swear by it," Jennifer said last month, purple bruises still clearly
marking her arms as she waited for a replacement pellet in September. "For
the first time in my life, I feel free. I'm not stuck having to go to a
methadone program every day and, if I want to, I can pick up and go to
Florida."

Though Gooberman's patients praise his work, medical professionals aren't
as starry-eyed.

In a February 1996 report, doctors at the National Institute on Drug Abuse
denounced ultra rapid detoxification as "without ethical, medical,
scientific or financial justification."

Detoxification while under anesthesia is too risky and elaborate, the
report said, when there are less expensive and less complicated methods. It
adds there's a 1-in-15,000 chance of serious complications, including
cardiac arrest, respiratory inhalation and death while under anesthesia.

The Board of Medical Examiners cites similar concerns along with the lack
of independent studies on its effectiveness. The board has until Dec. 31 to
make a decision on the ban.

"You want to be in an environment that can deal with complications, like a
hospital or acute care setting," said Paul Casadonte, director of the drug
abuse program for the New York Veterans Affairs Medical Center.

It's also reckless to discharge patients the same day, Casadonte added,
because complications can occur hours later. Plus, he said, no medical
procedure can work without psychological treatment, which Gooberman doesn't
provide.

Gooberman initially had weekly psychological sessions but abandoned them
because his patients, who he described as scholars, millionaire
businessmen, state troopers and prostitutes, come from all over the world
and don't want to stick around for counseling.

The naltrexone pellet is a crutch that gets addicts to stop using heroin
long enough to get into counseling though some patients, Gooberman
concedes, could be on naltrexone for the rest of their lives.

"The pellet gives them some breathing space," Gooberman said. "The pellet
does give a false sense of security. This is not a cure."

Experts don't argue that naltrexone helps addicts stay off heroin. The Food
and Drug Administration approved naltrexone for treatment of opiate and
alcohol abuse in the 1980s.

Under scrutiny is the long-term success of the procedure. Gooberman claims
a 99 percent success rate based on his follow-up study of 162 patients
after one month. He has no long-term numbers, however.

Naltrexone may block heroin's highs, but it doesn't stop an addict's
craving. Methadone, the standard in addiction treatment for 30 years, does
both. Used by 115,000 of 600,000 U.S. addicts, it's a legal but addictive
substitute for heroin that only lasts 24 hours, experts said. Yearly
treatment, including therapy, costs between $6,000 and $10,000.

"We try to stabilize addicts on methadone to get them off the streets and
stop committing crimes," Casadonte said. "The goal is eventually to bring
them down from methadone, but unfortunately that is not the usual course of
treatment. Like diabetics, some use it for the rest of their lives."

Other, longer-lasting medications are being developed. LAAM, an acronym for
levomethadyl acetate hydrochloride, and buprenorphine perform like
methadone but have longer-lasting effects. LAAM, used by 3,000 U.S.
patients, lasts 48 to 72 hours and buprenorphine, which is experimental,
lasts 98 hours.

For teens and college-age students, however, the rapid detoxification is
more appealing than trudging to a methadone clinic every day.

Robert Sniras Jr., 23, of Clifton Heights, Pa., is one addict who headed to
Gooberman instead of a methadone clinic after several failed rehabilitation
attempts. Sniras started using heroin in 1994 and his addiction escalated
to a $150-a-day habit.

Sniras had been clean two months when he returned to Gooberman for a
replacement naltrexone pellet in September. But he has refused to attend
12-step recovery, a self-help program, or Narcotics Anonymous meetings.

"If you don't go to meetings, you will use," Gooberman warned the tall,
thin man.

But the results are encouraging.

"So far (the pellet) has worked. That's why I'm here today," Robert Sniras
Sr. said as he waited for his son. "If I had to, I'd bring him back here
for a pellet for the rest of his life."

Checked-by: Mike Gogulski