Methadone Highway

Every day hundreds of Greater Cincinnatians drive Interstate 275 west to Lawrenceburg, exit at U.S. 50 and turn left toward the Argosy Casino -- but not to gamble.

Just before the casino entrance, they turn right onto Rudolph Way and head for an unremarkable office building at the end of the short road. There an aging security guard kindly opens the front door, revealing snack and pop machines, Ansel Adams and Successories prints on the wall and two windows dispensing daily doses of methadone.

To advocates, methadone -- a synthetic narcotic administered in tablet or liquid form -- is a lifesaving alternative to heroin and other illegal drugs. To others, methadone is little more than a substitute addiction.

Early one Saturday morning in January, most of the recovering addicts at the East Indiana Treatment Center wear flannel shirts, jeans, sneakers and baseball caps. An older woman shuffles across the floor with the aid of a walker. A young couple stands in line, looking as if they could be waiting for a bank teller or a new driver's license. It's impossible to tell the clinic's patients from its counselors.

Recovering opiate addicts go to the East Indiana Treatment Center to end their daily searches for heroin or their doctor-shopping for prescription painkillers such as OxyContin, Percocet and Vicodin.

The center's patients more than doubled from 689 in 1998 to 1,420 in 2000, according to state records. Only 91 of those patients lived in Indiana. More than half, 748, were from Ohio and most of the others, 581, were from Kentucky.

Taking medicine is not 'using drugs' The center doesn't attract a methadone caravan because its services are free. Patients pay an average of $11.50 for each daily dose of methadone at this private, for-profit clinic.

Nor do many patients from Cincinnati drive to Lawrenceburg because it's the closest clinic. A public methadone clinic, Central Community Health Board (CCHB), operates in Mount Auburn.

But they might drive to Lawrenceburg because of CCHB's street reputation for ineffectively low methadone doses and for limited treatment availability.

"We are under-serving our population, there's no doubt about that," says Dr. Roberto Soria, former director of TriHealth's drug and alcohol rehab program at the former Bethesda Oak Hospital.

The Ohio Department of Alcohol and Drug Addiction Services (ODADAS) -- which regulates the state's nine methadone clinics, including CCHB -- knows Ohioans are going to Indiana for methadone treatment. But treatment providers say ODADAS isn't interested in increasing the size or number of public clinics in Ohio, despite growing support for methadone treatment among federal officials, grass-roots advocates and medical professionals.

An ODADAS spokesperson says at least two private parties have asked about starting new clinics in the last year, but none of the requests came from county drug treatment boards. Maybe they know not to ask.

Many in the conservative Midwest, especially law enforcement officials, still regard methadone as just another drug of addiction. Luceille Fleming -- ODADAS' director since the department was created in 1989 -- shares that belief, according to Sherry Knapp, executive director of the Hamilton County Alcohol and Drug Addiction Services Board (ADS).

"She sees it as a kind of substitute drug," Knapp says. "She would not allow (its use) to grow -- ever -- even if the demand grows."

Total abstinence from all drugs is ODADAS' ultimate goal and a requirement of state law. Methadone is allowed, but only in "short-term cases where it is absolutely necessary," says Lisa Generette, a spokesperson for ODADAS. This total abstinence philosophy encourages clinics to gradually reduce methadone doses to wean addicts from all opiates.

But multiple relapses are common for long-term, chronic opiate addicts who try to stay off drugs completely.

Furthermore, studies show at least some opiate addicts benefit greatly from steady methadone doses, or methadone maintenance treatment (MMT). This approach has allowed many recovering addicts to put aside chronic addictions to heroin, pain pills and other substances with few adverse health effects.

"Methadone still seems to be the best for the most," says Mac Bell, an administrator of the Kentucky Narcotics Treatment Program.

No cure exists for opiate addiction, but methadone is the best treatment available, according to Dr. Gene Somoza, a psychiatrist for 130 methadone patients at the Cincinnati Veteran's Administration Hospital, the only other clinic in the Tristate. Somoza also heads the Cincinnati Addiction Research Center at the University of Cincinnati.

"We don't have anything better right now," he says. "Until we find a cure, we have no choice. Everything else is illogical when you know all the facts."

Root canals for a fix Most Tristate opiate addicts don't use needles to get high, according to Soria. Instead they snort heroin or abuse pain pills such as Percocet, Vicodin and OxyContin. Cincinnatian Brian Wilson's story might represent a typical Tristate case.

Wilson, 32, grew up in Bright, Ind., eight miles from Lawrenceburg and three miles from Harrison, Ohio. His dad has been a supervisor at a chemical factory for 35 years. Wilson's family treated him well and he never had to worry about material comforts.

At age 19 a doctor removed Wilson's tonsils and prescribed Percocet for pain. He took one and went to his part-time job at a fireworks stand the next day.

"It lifted me up and made me feel like I was in a good mood," Wilson says. "It put me on top of the world."

The next day he took two pills. When his prescription ran out, he looked for more. His friends pointed him in the right direction.

"In six months you can have a strong habit," Wilson says.

He always kept a job, despite his addiction. Compared to other drugs, pills were easy to hide. As time passed, the highs decreased and his daily dose increased. Soon the pills were just a way to feel normal again.

Three times Wilson was so desperate to avoid the severe, flu-like opiate withdrawal, he underwent unnecessary root canals just to get painkillers.

"Anything is better than having to go through the sickness (of withdrawal)," he says.

Many doctors don't have the training to recognize when addicts are getting a fix, he says. Others know but don't care.

"Some doctors are in it for the money," Wilson says.

Eventually, his wife of four years left him, granting joint custody of their son. One night he went out to drown his sorrows in alcohol. Before he made it home, he was arrested for drunken driving and lost his license for one year. Still on drugs, he drove anyway and ended up in the Dearborn County Jail for three months in 1999.

The jail term was the first time Wilson completely withdrew from opiates. The sickness lasted two weeks and included rounds of sweating, chills, fevers, vomiting and body-wrenching muscle cramps.

"You can't keep food down," he says.

Wilson had been to abstinence-based programs. He could stop using for a few days, but never longer. It was good to hear other addicts' stories and get their support, but he still had a physical craving for drugs.

"I've tried it," he says. "I've gone through 12-step programs four or five times."

By January 2000 Wilson was back on drugs but couldn't find pills, so he smoked heroin. Soon he was snorting it. He realized needles were next. With needles came the likelihood of hepatitis and AIDS.

Some of his friends had been talking about methadone. They said Cincinnati's public methadone clinic, CCHB, had a four-month waiting list. They offered to take him to Lawrenceburg.

Wilson met all the criteria for treatment, which he received almost immediately. He began with 30 mg, a standard first dose for a new patient. His tolerance required more, however, so now he takes 150 mg a day. Finding the right dosage is more about how the patient feels than numbers, he says.

Wilson swears by methadone. It's the only way he's been able to kick drugs.

"It turned everything around," he says.

But it hasn't been methadone alone; Wilson developed a completely new set of friends. Some of his old buddies died.

Wilson is the director of the Ohio chapter of Advocates For Recovery Through Medicine, a national group that backs methadone treatment. He believes methadone doesn't deserve the stigma many give it.

"I compare it to insulin," he says. "You never hear people tell diabetics they would be OK if they would just exercise and lose some weight."

You also never hear diabetics called insulin addicts, he says.

"I don't call it a habit," Wilson says. "There's a difference between having a habit and being dependent on a medication."

Without methadone, Wilson figures he would now be in jail, or maybe dead.

"I'll be dependent on it the rest of my life," he says.

It won't get you high, just healthy Many people question the validity of giving methadone to addicts. How can it be good to treat drug addicts with another drug? Isn't the only responsible lifestyle totally drug-free?

In the early 1940s, German scientists invented methadone as a replacement for morphine, scarce during the war. In 1967, when researchers didn't understand why heroin addicts would risk their lives to get drugs, psychiatrist Dr. Marie Nyswander and biochemist Dr. Vincent Dole of Rockefeller University proposed treating heroin addicts with methadone.

They found regular methadone doses ended addicts' desire for heroin without any adverse health effects, allowing them to begin working on the rest of their lives.

Methadone is an opiate, as are heroin, morphine and some prescription painkillers. But unlike illegal drugs, methadone does not provide a high to people who have a tolerance for opiates.

"Methadone programs don't get people high," says Anthony Tommasello, the director of the Office of Substance Abuse Research in the University of Maryland's School of Pharmacy. "They just help people, in the street vernacular, get 'copacetic.' "

Drugs such as heroin flood the body's opiate receptors with chemicals that simulate the body's natural, pleasure-stimulating chemicals. Over time, the body's opiate receptors adjust to the unusually high levels of drugs and require even higher doses to produce the same euphoria. If the supply ends, the body goes through withdrawal. The deeper the addiction, the deeper the withdrawal.

A dose of heroin lasts four to six hours. A proper dose of methadone satisfies the body's demand for opiates for 24 hours. At the same time, it's an antagonist, blocking the effect of Vicodin, heroin and other opiates.

Just ask Wilson. Early in his methadone treatment, he took seven extra-strength Vicodins to see if he could get high. They had no effect.

Methadone has no effect on stimulants such as cocaine, an important limitation because some addicts abuse a variety of drugs.

While heroin and other illegal opiates act as severe depressants, methadone doesn't affect memory, the ability to do skilled tasks or other brain functions, according to Dr. Avram Goldstein, professor emeritus at Stanford University and author of the 1994 book, Addiction: From Biology To Drug Policy. In 1969 Goldstein established an MMT program in San Jose, the first in California.

For those who want to quit but couldn't succeed in 12-step, abstinence-based programs or gradually wean themselves from methadone without relapsing, MMT can be a platform for other lifestyle changes that allow people to overcome their destructive behavior, Goldstein wrote.

On the whole, about one-third of addicts don't respond to MMT, one-third have some success and one-third never use opiates again, Goldstein wrote.

Indiana uses a four-point scale to track the progress of its methadone patients: none, little, moderate and significant. As of Dec. 31, 2000, significant reductions came from:

·44 percent of 4,143 people who had abused prescription opiates,

·44 percent of 5,202 people who had abused non-prescription opiates,

·36 percent of 4,074 people who had engaged in criminal behavior and

·35 percent of 3,905 people who had engaged in risky behavior concerning infectious diseases.

Ohio and Kentucky don't keep such detailed records, although Kentucky and the Hamilton County ADS Board are beginning to gather them.

More striking are the bottom-line health benefits for addicts. Recovering addicts on MMT were 70 percent less likely to die than those who weren't, according to a 1997 statement by the National Institutes of Health.

Sometimes local Veteran's Administration Hospital patients ask Somoza to take them off methadone. Usually Somoza slowly reduces their methadone over six months.

"In every case, sooner or later, they got back to using heroin," Somoza says.

For example, one of his clients came from a New York prison that offered MMT and married a Cincinnati woman. He had been taking methadone and was stable for three years. Then they joined a church that favored total abstinence.

Somoza lowered the man's methadone dose over six months until he was drug-free. Everything seemed fine until an old friend from New York dropped in and offered him a hit. Within four months the man was back on his old heroin habit.

Somoza later ran across the man in an emergency room and discovered his wife had left him and he was homeless. The man began using methadone again, and within 18 months his wife had taken him back. Then the church re-entered the picture and the whole cycle repeated itself.

"There's no real downside to being on methadone except the 'sin' of being on it," Somoza says.

In contrast, about 90 percent of Somoza's MMT patients have opiate-free urine tests and about 80 percent are clean of all drugs except alcohol and marijuana.

"Occasionally, there are some people who can get off (opiates), but they are people who never were addicted," Somoza says.

Addiction seems to be partly connected to a person's ability to handle stress, Somoza says.

"The relationship between stress and addiction is fairly tight," he says. "The theory is that people who get addicted are people who can't comfort themselves."

Other research is focusing on the relationship between depression and addiction and whether or not long-term addiction permanently changes the body.

Doses are better in Lawrenceburg Recovering opiate addicts should be able to go to CCHB in Mount Auburn and receive treatment within 14 days, according to Lillian Toles, CCHB's director since 1985. The clinic serves up to 150 methadone patients at a time, plus 150 addicted to alcohol and other drugs.

"We turn very few people away," Toles says.

But many more drive to Lawrenceburg every day, sometimes getting treatment in the same day, like Wilson. If the patient shows steady progress for three months, as Wilson did, they qualify for take-home doses -- first a few days' worth, then a week's worth. Ohio requires two years of steady progress for take-home doses.

That's meaningful because it's a 52-mile round trip from Fountain Square to the East Indiana Treatment Center. Although Toles plays down any difficulty of getting into CCHB, its reputation -- deserved or not -- has reached Indianapolis.

"My experience is that you have big waiting lists," says John Viernes, deputy director in the Indiana Department of Mental Health and Addiction's Office of Public Policy.

Knapp says it's possible many recovering addicts don't go to CCHB because they think they can't get in, like Wilson. But that's not the only reason. Wilson's friends also told him CCHB provides the lowest possible dose. Soria has also heard about it.

"That's well-known," he says.

CCHB's doses average 40 to 60 mg but go as low as 10 mg and as high as 100 mg, according to John Silvany, CCHB's methadone program director since 1989. Bennett J. Cooper Jr., executive director of CCHB, says doses are adjusted case-by-case.

Toles and Knapp say Ohio requires approval from two physicians before a clinic can exceed 100 mg per dose. But Generette says Ohio doesn't impose any limit on doses.

The correct dose can be affected by diseases, such as hepatitis C, contracted by as many as 85 percent of heroin addicts, according to Somoza. Hepatitis-positive patients need a higher dose than others.

"It depends on weight and height and what they were doing on the street," Bell says.

The average effective dose in Kentucky's clinics is 80 to 120 mg, he says. Nearly all clinics start at about 30 mg and increase until reaching an effective dose. Wilson knows of people on as much as 1,500 mg.

Soria says most studies say that low-dosing isn't as effective as higher doses. If the dose doesn't satisfy an addict's craving for opiates, he'll use something else as well. Nor does a low dose block the effect of other opiates.

"If you want to ensure failure, you use a low dose," Goldstein says.

Marcie, a former CCHB patient who now lives in Northern Kentucky, relapsed five times while under its care. Marcie, who asked that only her first name be used, later learned she had received as little as 13 mg of methadone per day. Marcie, who has hepatitis C, now takes 150 mg a day from the East Indiana Treatment Center. She relapsed once early in her recovery, but not since.

"I always wanted to be clean," she says.

Marcie says she never knew how much methadone CCHB was giving her -- a practice known as "blind dosing." Wilson says that's another reason people don't go to CCHB.

About one-third of methadone clinics use blind doses, according to Silvany. They do it because recovering addicts sometimes try to brag to friends about how high a dose they take.

"It's kind of a badge of courage," Silvany says. Some patients do know their doses; it's up to the counselor, he said.

Soria says it's important for recovering addicts to believe their doctor and counselor. Blind doses aren't a good way to build this trust, he says.

"You're treating them like an adolescent," Soria says.

Toles says some people who go to Lawrenceburg just aren't interested in getting treatment with counseling and therapy.

Cooper, whose father was a supervisor in the Ohio prison system in the early 1970s, says recovering addicts sometimes need a confrontational style of treatment. Talking too much about doses can be a distraction, he says.

Both clinics have counselors. The major problem at East Indiana, Wilson says, is its high counselor turnover rate. The counselors there are inexperienced in general; state rules require only a bachelor's degree in any subject, he says.

But even Toles agrees the state is under-serving parts of southwest Ohio -- specifically Butler, Warren and Clermont counties. The next-nearest methadone clinic is in Dayton.

Cooper, who once had Toles' job, used to believe indefinite methadone treatment wasn't a solution, even if it kept addicts out of jail and off other drugs. Now he doesn't draw such a hard line.

"I would consider that a partial success," Cooper says.

See no evil, treat no evil In 1997, Kentucky drug treatment officials were working with MX Group Inc., an Erie, Pa. company, to open a clinic in Covington. Six other private clinics opened all over the state in the late 1990s to meet a growing demand for methadone treatment. The state runs two public clinics that offer less-expensive services.

But the Covington Board of Adjustment denied the application and the city has been fighting the clinic in court ever since. The issue is headed for a hearing March 19 in the U.S. Sixth Circuit Court of Appeals in Cincinnati. The dispute is over whether MX Group has a constitutional right to open a clinic in Covington.

MX Group's attorneys, William Oldfield and David Davidson of Covington, believe opiate addiction is covered under the Americans with Disabilities Act (ADA) and the city must allow a clinic under the its current zoning.

"The big issue is whether the ADA applies," Oldfield says.

Methadone clinics have won similar cases in White Plains, N.Y., and in Antioch, Calif. In August 1997, MX Group applied for a site at an old West Pike Street train depot that had been converted to office space. The city's zoning administrator says the site met the city's legal requirements, but the clinic would have been two blocks from a school. Predictably, the city, the Covington Business Council, parents and others were upset.

Almost everyone who went to a September 1997 public hearing about the clinic had their minds made up, according to Melissa Fabian of Fort Wright, who has degrees in psychology and coursework in criminology and would have been the clinic's director.

"They just wanted to show us how angry they were," Fabian says. "They just did not want a treatment facility there."

Fabian completed the state-mandated demand assessment survey that justified opening a clinic, in part by checking arrest records and hospital admissions. The nearest Kentucky clinics are in Lexington and Louisville, 90 miles away. CCHB only can treat Hamilton County residents.

"We just didn't haphazardly decide we're going to plop down here and see if people will come," says Fabian, who now works for the Jewish Native Fund in Blue Ash.

Fabian talked about Kentuckians having to drive to Lawrenceburg for treatment. But opponents focused on the likelihood that a new clinic in Covington would attract addicts from Ohio.

"I just think it would create more of a criminal element," says Covington Mayor Butch Calley.

Calley supports taking the case to the U.S. Supreme Court. Money isn't an issue, he says.

But the whole matter might soon be moot. Kentucky is processing an application for a methadone clinic in Florence, Bell says. The applicant, who Bell declined to disclose, has finished some of the work but still needs approval from the U.S. Drug Enforcement Agency (DEA) and final approval from Kentucky.

Methadone beats dying Those who don't flinch when social services are cut should consider some numbers. The DEA's budget in 2000 was more than $1.55 billion -- 20 times what it was in 1973. Fifty-five percent of federal prisoners and 20 percent of state prisoners are behind bars for drug-related crimes. At least 70 percent of the inmates at the Hamilton County Justice Center violated drug laws or have drug problems, according to Knapp.

Yet no state prisons in Indiana, Ohio or Kentucky offer any methadone treatment; nor does the Hamilton County Justice Center. All insist on abstinence-based treatment. Kentucky prisons can only provide general drug treatment to 17 percent of prisoners, according to Dr. Rick Purvis of the Kentucky Department of Corrections.

Kentucky, which suffered an outbreak of OxyContin abuse in recent years, allowed six new private, for-profit clinics to open since 1995 to complement its two state-funded clinics, according to Bell.

Indiana began a five-year moratorium on new clinics in 1998, but it already had 13 -- almost three times the number per capita in Ohio.

But don't expect Ohio to allow new private clinics to complement its nine public ones. The state's methadone regulations effectively prevent this from happening, according to Soria, who researched the possibility while working at Bethesda. Any clinic that wants to dispense methadone must first offer non-methadone drug rehab for two years -- a hurdle that private clinics can't clear, he says.

ODADAS is concerned that for-profit clinics will exploit recovering addicts and wants them to establish a track record, according to Generette.

Getting a new public clinic might not be any easier. At least four local hospitals have cut or reduced their drug treatment programs, according to Soria. Knapp says the Hamilton County addiction board's funding allows it only to maintain existing programs.

Ohio is not proactive about methadone, according to Bell.

"They just don't want to deal with it," he says.

Treating addiction requires more than handing out methadone, Soria says. Recovering addicts need counseling.

"We need treatment, not just dosing," Soria says. "Dosing isn't treatment."

Although states are still left to manage their own programs, the federal government is in the middle of standardizing some parts of methadone treatment, including the availability of take-home methadone doses.

The National Institutes of Health have called for increased access to MMT. Advocacy groups such as the American Methadone Treatment Association are joining the call. Even Barry McCaffrey, former director of the White House Office on National Drug Control Policy, said in 1998 he supports making MMT more available.

Bell is still fighting for acceptance of MMT. State legislation ending MMT might be proposed in the Kentucky Senate soon.

Methadone is a powerful drug that can be abused if handed out too freely. One person died from a methadone overdose in Hamilton County from Jan. 1, 2000 to Dec. 31, 2001, according to the Hamilton County Coroner's Office. But 25 others died from overdoses or likely overdoses of heroin or other opiates.

A few of those who died had recently been released from prison, and a few had received methadone treatment at East Indiana in Lawrenceburg or the Veteran's Administration Hospital, but they were exceptions.

Most of those who died had jobs, including a 30-year-old waiter at a downtown hotel, a 20-year-old legal secretary who had finished a non-methadone treatment program and a 51-year-old construction worker. Many were white males in their 30s and 40s.

It's impossible to say if treatment would have saved any lives. But Wilson knows one thing for sure -- getting heroin is easier than getting methadone treatment.

"I could take you downtown and could get heroin in 10 minutes." He says. "Take it from somebody who knows from being there. And it's getting cheaper and cheaper and cheaper."

Drug Abuse, By The Numbers

14 million -- number of Americans who used some form of illegal drugs in 2000

130,000 -- estimated number of opiate (heroin, etc.) users, age 12 and older, in the United States today

33,000 -- estimated number of heroin-related emergency room visits in the U.S. in 1990

96,000 -- estimated number of heroin-related emergency room visits in the U.S. in 2000

5,211 -- number of OxyContin-related emergency room visits in 1998

10,825 -- number of OxyContin-related emergency room visits in 2000

$21,140 -- average annual cost of keeping an inmate in a state prison in 2000

$2,941 -- average cost of drug rehabilitation of all kinds, per treatment episode in 1999

$2,575 -- average cost of an outpatient methadone program, per treatment episode in 1999

$11,462 -- average per addict cost in crime in the year before treatment of any kind

$2,851 -- average per addict cost in crime in the year after treatment of any kind

20 percent -- U.S. state prison population arrested for drug-related charges in 1999

3,384, or 16.3 percent -- number of people in federal prisons for drug-related charges in 1970

75,625, or 55 percent -- number of people in federal prisons for drug-related charges in October 2001

31 percent -- amount above capacity federal prisons were operating in December 2000

$74.9 million -- Drug Enforcement Agency's annual budget in 1973

$1.55 billion -- Drug Enforcement Agency's (DEA) annual budget in 2001

2,898 -- number of DEA employees in 1973

9,132 -- number of DEA employees in 2001

SOURCES: Drug Abuse Warning Network, Criminal Justice Institute's 2000 Corrections Yearbook, Bureau of Justice Statistics, U.S. Drug Enforcement Agency, Center for Substance Abuse Treatment.


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