A FRESH LOOK AT A QUICK FIX FOR HEROIN ADDICTION

The patient strapped to the hospital gurney, breathing through a
respirator, is James, a 40-year-old man addicted to heroin. The
anesthesiologist loads a syringe with 20 milligrams of naloxone and slowly
injects it into the IV in James's right arm. During the next 10 minutes,
the drug will enter his system, pry off the billions of opiate molecules
that have been clinging to his brain cells and wash them away.

This is a rather abrupt way to come off heroin. Were it not for the
anesthesia holding him in a state of unconsciousness, James would be
writhing, shivering, vomiting and perhaps screaming in pain. Even in his
deep sleep, his heart rate and breathing speed up, his pupils dilate, his
nose runs, his temperature rises, his arms and legs twitch sporadically and
his skin erupts into gooseflesh.

Over the course of the next four hours, as the opiates are flushed out
through his liver and kidneys, his heart rate, breathing and temperature
fall back to normal, his pupils readjust and his goose bumps recede. When
he is awakened, his body is fully detoxified from heroin — a process that
can normally take days or even weeks.

After a night in intensive care, James returns to his family in Queens and,
a few days later, to his job as an executive chef at a Manhattan hotel
restaurant. For a few weeks, he has trouble sleeping, and he feels achy and
weak, as if he had the flu. Every day, he attends meetings of Narcotics
Anonymous. And every day, he swallows a tablet of naltrexone, a drug that
prevents heroin and other opiates from affecting his brain.

This is rapid detox, a practice invented in Austria at the University of
Vienna in the late 1980's. In the world of addiction medicine, no technique
for treating heroin users has ever been more controversial.

Five years ago, when the procedure was introduced in this country, it was
offered at only a handful of hospitals. Two years ago, seven patients died
soon after rapid detox performed by one New Jersey doctor, who had
conducted some 3,200 procedures. The technique was widely condemned.

But it has continued to be practiced. Dr. Clifford Gevirtz, an associate
professor of anesthesiology at the Mount Sinai medical school in Manhattan
and the Bronx Veterans Affairs Medical Center, estimates that about 1,000
procedures a year are done in this country. In Europe, 12,000 are performed
each year, chiefly in Spain, England, Germany, Belgium and the Netherlands.
But the numbers are likely to rise, if clinical trials show that the
procedure is safe.

"Patients want it," Dr. Gevirtz said, "because it gives them a
compassionate and comfortable way to get clean." Until recently, Dr.
Gevirtz performed rapid detox at Metropolitan Hospital Center in Manhattan.

In addition to heroin addicts, people who became addicted to painkillers
after injuries or operations have also sought the procedure.

Many doctors say that until more research is done, rapid detox, which costs
anywhere from $3,500 to $8,000 and is usually not covered by insurance, is
too risky. And, they say, unless strong measures are taken to keep patients
from returning to heroin use, rapid detox, even if it is safe, may not be
worthwhile.

"I view it as more of an experimental procedure," said Dr. Patrick G.
O'Connor, a professor at Yale University School of Medicine, who has
studied rapid detox. "We really need to understand it more before we start
using it willy-nilly."

Dr. Mary Jeanne Kreek, an addiction researcher at Rockefeller University,
said: "We don't need this approach. We have several good approaches, and
this one is a waste of money."

Jennifer Sandu, a spokeswoman for the New York State Office of Alcoholism
and Substance Abuse Services, said, "It is an expensive procedure, with no
proven benefit over less expensive existing methods."

Occupying a middle ground are addiction experts who believe that rapid
detox may turn out to be useful for certain patients.

"It's not chicanery or malpractice," said Dr. Michael Miller, a
psychiatrist at the University of Wisconsin Medical School, who is chairman
of the public policy committee of the American Society of Addiction
Medicine. "There is a good body of science that supports what is being done
and why. The question is, Is it necessary? There are other methods of detox
which are effective, safe and cheap."

Dr. Bennett Oppenheim, a psychologist who runs UltraMed International, a
company in Fort Lee, N.J., that offers rapid detox (and where, until
recently, Dr. Gevirtz was chief medical officer), said his patients
included a wide range of heroin users. At one end, he said, is "the guy who
has nothing, but grandma's paying for his detox," and at the other end are
"high-profile celebrities of sports and entertainment whose names you would
definitely recognize."

A majority, Dr. Oppenheim said, have tried other ways of getting off
heroin, have relapsed and are afraid to face withdrawal again. Or, they are
people who want to come off methadone maintenance.

Some 980,000 Americans use heroin, the Office of National Drug Control
Policy says. About 175,000 are now enrolled in government-regulated
programs where they receive a daily dose of methadone.

Dr. Miller said rapid detox might turn out to be useful for select people
who needed to detoxify quickly. These may include addicts who have
developed severe gastrointestinal side effects to opiates, or those who
need to begin taking antidepressants for newly diagnosed depression.

A growing group of patients, providers say, are people who have become
dependent on pain medications — "your soccer mom who became dependent on
morphine after a car accident," Dr. Oppenheim said. Perhaps as many as one
in 100 people who take prescription drugs for chronic pain are
opiate-dependent, Dr. Gevirtz said.

One reason for the atmosphere of suspicion surrounding rapid detox is the
perception that some hospitals offer it merely because it is a good
cash-only business. Also, some practitioners have tried to patent the use
of medications in rapid detox, drawing further disapproval from their peers.

One standard way of detoxifying people from opiate addiction is by
switching them to methadone, a synthetic narcotic that mimics heroin, and
then tapering the methadone over a period of days or weeks.

Another method is to give the patient clonidine, a drug used to treat high
blood pressure, which can help quiet the jittery symptoms of withdrawal.

A third strategy, which may soon come into wider use, is to prescribe a
drug called buprenorphine, which, like methadone, mimics heroin's effects,
but even more mildly. Unlike methadone, which is distributed only in daily
doses through government-regulated clinics, buprenorphine could be
prescribed in weekly, or even monthly doses, by private physicians. The
Food and Drug Administration is now deciding whether to approve it.

Rapid detox, Dr. Gevirtz said, can be as safe as any other strategy. At a
meeting of the American Society of Anesthesiologists in October, he
presented an analysis of the seven New Jersey deaths, which occurred from
one to three days after rapid detox performed in the Camden County office
of Dr. Lance L. Gooberman.

All but one of the deaths were caused by pulmonary edema, a buildup of
fluid in the lungs. In the other case, the patient vomited and breathed
some of the material into his lungs, which caused a fatal bacterial infection.

Dr. Gevirtz concluded that both problems could have been avoided. He
faulted Dr. Gooberman for not having a board-certified anesthesiologist
present. Anesthesia was administered by a nurse anesthetist.

(The New Jersey Board of Medical Examiners now prohibits Dr. Gooberman from
performing rapid detox.)

Dr. Herbert Kleber, a psychiatrist who is conducting a clinical trial of
rapid detox at Columbia University, said that keeping patients in the
hospital overnight could minimize the risks, but that even then, it was not
yet clear that the technique was safe. "The fact is, we still don't know
why some people die," Dr. Kleber said. "What causes the pulmonary edema?"

In addition to the deaths in Dr. Gooberman's practice, there was another
death two years ago in Massachusetts, and there have been at least two more
in Europe. Researchers say there may be some inherent danger in giving
prolonged anesthesia to someone whose heart function or body chemistry is
already compromised by heroin use.

"I think there may be a role" for rapid detox, Dr. Kleber said. "I think
that we need as many arrows in our quiver as possible. But science must be
driven by data. And I'm waiting for the data."

The second major issue is whether the treatment can stick. Heroin addicts
are notoriously resistant to permanent recovery. More than 80 percent of
addicts who manage to withdraw from heroin eventually go back to it.

Dr. David Cullen, an anesthesiologist at the Tufts University School of
Medicine, said the high rate of relapse was what had led him to stop doing
rapid detox. He had performed the procedure on 43 patients, but within a
year or two, more than 80 percent were either back on heroin or dead from
an overdose.

"This is a safe and effective procedure," Dr. Cullen said. "That's not the
issue. One hundred percent of our patients are detoxed when we finish with
them. But until psychologists figure out a better way to deal with these
patients, I don't see the point."

Other practitioners argue that the return to addiction is a separate
problem, not a reason to condemn rapid detox. "You have to think of
addiction as a chronic relapsing disease," said Dr. Gevirtz. "It might take
a couple of goes at detox."

Dr. Kleber of Columbia recently released some preliminary data showing that
three months after surgery, about 50 percent of rapid detox patients were
still heroin-free. "I stress that these data are preliminary," Dr. Kleber
cautioned.

The way to promote long-term abstinence, Dr. Oppenheim and others say, is
to see that patients get counseling for many months after rapid detox and
continue to take naltrexone so that they are not in danger of returning to
opiates.

As for James, it has been nearly three months since his detoxification. The
side effects afterward, he says, were somewhat worse than Dr. Oppenheim led
him to believe they would be. Nevertheless, he said, after spending $25,000
on heroin in 14 months, the $7,000 cost of the procedure was worth it.

James said it would not have worked without the support he had received
from his family and from daily attendance at Narcotics Anonymous. "It put
me in the right direction," he said, "but it's not a magic cure."