FOR ADDICTS, RELIEF MAY BE AN OFFICE VISIT AWAY

IN years to come, drug addiction will probably be treated like
hypertension, diabetes and other chronic, relapsing diseases: with a
variety of medications prescribed in the doctor's office.

This month, the Federal Drug Administration announced the approval of two
prescription drugs for heroin addicts: buprenorphine (a partial opiate that
produces minimal mood alteration) and buprenorphine-naloxone (a combination
with an opiate blocker). Studies over the past decade suggest that these
medications may be as effective as methadone in reducing opiate use and
retaining addicts in treatment programs.

Methadone - the treatment of choice since the 1960's - produces a high when
taken orally, even more so when injected. But buprenorphine-naloxone does
not produce euphoria when taken orally, and if injected it will actually
make an addict feel sick. Buprenorphine-naloxone also has a much lower
potential for overdose and withdrawal symptoms than methadone, and it has
to be taken less frequently - once every two to three days as opposed to daily.

Even more important, buprenorphine-naloxone can be dispensed in the privacy
of a doctor's office, a result of the Drug Addiction Treatment Act of 2000,
which was written in anticipation of this new generation of medications.
The hope is that by allowing addicts to avoid visits to centralized
methadone clinics, the stigma will be removed from seeking treatment and
more patients will seek help in the early stages of their addiction.

Senator Carl M. Levin, Democrat of Michigan, a co-sponsor of the law,
called the legislation "a revolutionary step by the federal government in
treating heroin addiction as a disease rather than a moral failing."

"It will have huge social benefits in the reduction of crime, incarceration
and health care costs," he added.

Another sponsor of the law, Senator Orrin G. Hatch, the Utah Republican,
stressed that it was not intended to decriminalize heroin use. "I certainly
don't condone drug abuse," he said. "But for those who have made bad - and
illegal - choices and find themselves caught in the throes of dependency on
illicit drugs, help is on the way."

Some experts say the new era in addiction treatment will inevitably affect
the debate over the decriminalization of drugs. If heroin abuse is just
another treatable condition, is heroin still a dangerous social menace?

"The combination of developing and approving new anti-addiction drugs and
the new law allowing their treatment in a private doctor's office
represents a real sea change," said Alan Leshner, chief executive of the
American Association for the Advancement of Science and the publisher of
Science magazine. "It is a flat-out demonstration that we are viewing
addiction as a bona fide disease."

Methadone remains the gold standard in treating opiate addiction -
especially for heroin users who have longstanding habits and require large
doses. But medications like buprenorphine-naloxone provide patients with
more choices and may prove especially helpful in the early stages of addiction.

Said Dr. Herbert Kleber, a Columbia University psychiatrist who specializes
in addiction treatment: "Medically oriented treatments can be quite
effective. In addition, addiction treatments have been effectively combined
with legal sanctions such as drug courts and court-mandated treatments."

Dr. Frank Vocci, a researcher at the National Institute of Drug Abuse who
has been involved in clinical trials of buprenorphine since 1989, cautioned
that the comparison between buprenorphine-naloxone and methadone should not
be an either-or question. "How can you tell when a patient walks in the
door which medication is the best?" he asked. "One size does not fit all."

Dr. Leshner agrees. "Some addicts will do better with methadone, others
with buprenorphine and some with behavioral therapies or combinations of
these options," he said. "The goal is to increase the time intervals
between such relapses."

It may be some time before the new drugs become widely available. For one
thing, it is unclear how many doctors are qualified - or willing - to treat
drug addicts in their offices.

The federal Office of National Drug Control Policy estimates that there are
1.1 million heroin addicts, and only some 200,000 are enrolled in methadone
programs. The new law requires doctors to take an eight-hour course on the
use of buprenorphine-naloxone, and each doctor, or group practice, can
treat up to 30 patients.

At present, about 5,000 doctors are qualified to offer the new treatments -
which means, at best, only 150,000 addicts can get it with privacy. By
early next year, however, addiction specialists hope to offer the training
at all the annual meetings of primary-care doctor associations.

Another issue is who will foot the bill. Medicaid does not provide
reimbursement for either methadone or the newer medications. Mark Parrino,
president of the American Association for the Treatment of Opioid
Dependence, which represents about 740 of the nation's 950 for-profit
methadone clinics, said that while third-party private insurers will most
likely reimburse the new, office-based treatments before long, "the real
debate will be over the involvement of publicly funded insurers like Medicaid."

Senator Levin agreed, saying that "since many heroin addicts do not have
medical insurance, we need to work on this issue."

Finally, there is the larger issue of personal responsibility. As Dr.
Kleber noted, "addiction is both a physical and a behavioral disease."

"No matter what medications we have, it doesn't do any good if the patient
doesn't take them or uses them occasionally," he said. "It is good to have
many different approaches and choices as we treat addiction. I need many
arrows in my quiver."