No one's quite sure how addiction works-why among a group of friends who share a few lines of coke or a balloon of heroin at a party, one becomes an addict and the other nine never pass the point of being recreational users. Or why one person can toss out a bottle of leftover Vicodin once he's recovered from his back sprain while another finds himself doctor shopping for prescriptions, unable to function without more and more pills. Genetics and environment play a role, though there are always exceptions to the rule.
One thing is certain: Addiction changes a person's brain chemistry to the point where the brain can't function normally without the drug. Drugs become all a person thinks about because they are, literally, all the brain wants. Few addictive substances take over the brain quite like heroin.
"Telling a heroin addict to just say no is like telling someone who's bipolar to have a nice day" is how Dennis Whitmyer puts it.
Whitmyer is the Southern California director for CRC Health. CRC operates five drug treatment facilities in San Diego County serving roughly 1,500 addicts, the majority of whom show up every day, 365 days a year, to receive a dose of methadone in the form of a pink, cherry-flavored liquid that they count on to keep their drug cravings at bay.
Last October, the same week wildfires broke out around San Diego County, a couple thousand doctors, nurses, drug counselors and public officials gathered at the San Diego Sheraton for the annual meeting of the American Association for the Treatment of Opioid Dependence (AATOD), the national trade organization for providers of what's known as medically assisted drug treatment. While there are a small handful of drugs used to treat opiate addiction, methadone is the biggie and received much of the focus at the conference, where featured speakers comprised a who's-who of the drug-treatment world, from the current head of California's Department of Alcohol and Drug Programs to the director of the national Center for Substance Abuse Treatment. San Diego Mayor Jerry Sanders was scheduled to give a welcome speech, though he had to cancel because of the fires.
Whitmyer, who chaired the conference's hospitality committee, noticed an absence among attendees-no one from the County of San Diego, the region's overseer of public-health programs, signed up to attend.
"That was a national program that was attended by 2,000 people and there was no one from the county there, in our own backyard, to learn about the benefits of medically assisted treatment," Whitmyer said.
No one was there because medically assisted drug treatment, also referred to as narcotic-replacement therapy, is not a service the county provides. Politics and cost-likely more the former-appear to be the reasons why, and the county's not alone in its refusal to embrace what Kathy Jett, director of the Division of Addiction and Recovery for the California prison system, referred to as "one of the most stigmatized fields there is, despite all the research.""
Methadone, like heroin, is an opiate. Like heroin, it binds to opiate receptors in the brain; but, unlike heroin, it doesn't produce a euphoric effect. When used in a drug-treatment setting, methadone eases the debilitating symptoms of opiate withdrawal and, when accompanied by counseling, allows a recovering addict's focus to be not on the sickness and craving that accompany withdrawal but, rather, on getting her or his life in order. An added bonus of methadone is that since it binds to opiate receptors, an addict on methadone who injects heroin won't experience a high because the seat's already taken.
In medical literature and position statements by drug-treatment organizations and advocacy groups, methadone is referred to as the "gold standard" for treating opiate addiction, with studies pointing not only to its medical benefits, but social benefits as well. For instance, a study released last April by the National Institute on Drug Addiction found that heroin addicts who were wait-listed for treatment were more likely to actually enroll in treatment-and less likely to be involved in criminal activity-if they're put on methadone in the interim.
But, out in the real world, methadone's been plagued by problems of misuse and lingering stereotypes.
"When you start talking about methadone, everybody gets the same visceral gut reaction," said John Peloquin, vice president of operations for CRC's Southwest Division, "that it's a seedy-looking little facility that you go to the back door and knock on the door three times and you get your fix of methadone."
Though it's not available without a prescription, there's a high incidence of methadone street-sales to addicts looking for something to hold them over until their next fix. And, during the past decade, the drug has become a popular pain medication-used more widely for pain management than addiction treatment, in fact-because of its low cost compared with other prescription painkillers. But, after a significant increase in fatalities from methadone overdose-up 390 percent since 1998-on Jan. 1 of this year, the Drug Enforcement Administration put a moratorium on doctors prescribing 40-milligram methadone tablets in non-treatment settings; pharmacies can no longer stock 40-milligram tablets, either (5- and 10-milligram tablets and the liquid form are still available, however).
Like the drugs it's designed to combat, methadone creates physical dependence-users must wean off the drug under a doctor's supervision-though the withdrawal symptoms aren't as severe as heroin withdrawal. Methadone's not a quick-fix for addiction, either. In one mid-'80s study involving 671 addicts, 92 percent of participants who stuck to a methadone-treatment program for four-and-a-half years stayed clean. But of the 105 patients who stopped methadone after one year, 82 percent went back to using drugs. In terms of publicly funded drug-treatment programs, having to make a long-term commitment to an addict might not sit well with taxpayers.
No one wants to be tied to a prescription drug for the rest of their life, Peloquin said-the goal is to stabilize a person and then start them on the process of weaning off methadone. But, "if a patient has 20, 30 years of hardcore drug abuse, the patient's brain chemistry has altered so much that they may never find themselves off of methadone," he said.
San Diego is the largest county in California that neither provides medically assisted drug treatment nor contracts with any providers that do. Drug-treatment providers that get funding from the county operate under a drug-free model, also known as social-model treatment, meaning anyone enrolled in their programs must abstain from any substance that could result in dependence, even if that substance is helping them kick their habit. A person who enters a county drug-treatment program on methadone might as well have entered the program on heroin.
The drug-free treatment model carries over to the criminal justice system, too. San Diego County's Drug Court, a diversion program that offers nonviolent offenders the option to enter treatment rather than jail, forbids medically assisted treatment. And of the $9 million San Diego County receives annually to pay for Prop. 36-the statewide drug-treatment initiative that's based on the drug-court model but with more lenient probation rules-none of that money funds medically assisted treatment.
Of the state's 21 largest counties, San Diego is one of only five that doesn't allocate any money for narcotic-replacement therapy (NRT), even though state officials have consistently recommended that it be included as a treatment option because of its proven success rate. In a final report on Prop. 36's first five years, published last April, researchers from UCLA found that only between 10 and 15 percent of Prop. 36-eligible heroin addicts were referred to NRT, but of that group, 71 percent successfully completed treatment. Meanwhile, 52 percent of heroin addicts who entered a drug-free treatment program successfully completed it.
"Heroin users' performance in treatment may improve significantly if NRT is made more available," the UCLA report concluded.
Susan Bower, head of San Diego County's department of alcohol and drug services, explained that the county doesn't fund medically assisted drug treatment because clients who opt to go that route can pay out-of-pocket or apply for state assistance. A 1994 legal settlement ordered the state to fund methadone treatment for anyone who qualifies for what's called Drug Medi-Cal, which has basically the same eligibility requirements as regular Medi-Cal.
"It doesn't mean there's any more or any less services because of that," Bower said. (Whether Prop. 36 clients know that self-funded or state-funded methadone treatment is an option isn't clear; a spokesperson for the county said that drug-treatment providers who contract with the county can refer patients to methadone programs if the provider thinks that's the patient's best option, but two law-enforcement officials who work with Prop. 36 clients were unaware of any sort of referral system, and a spokesperson for the California Department of Drug and Alcohol Programs said their records show that no San Diego County Prop. 36 participants have been referred to narcotic-replacement therapy between the program's start in 2001 and 2006, the most recent year for which numbers are available.
The decision not to fund methadone is also a matter of limited resources, Bower said. "[If] we chose to take money from current treatment programs and shifted that over to fund methadone, that means waiting lists in other treatment programs."
Then there's the fact that heroin addiction isn't the epidemic it once was. As Richard McCue, a deputy district attorney who oversees three of the county's drug courts, said, "I don't want to sound cavalier about it, but within the context of the people we are working with, heroin addiction is rare. What we're seeing is methamphetamine, methamphetamine and more methamphetamine."
Methamphetamine may have surpassed heroin in numbers of new addicts, but prescription opiate abuse-OxyContin, hyrodcodone, Vicodin-is on a slow creep. In January, the Community Epidemiology Working Group (CWEG), a panel of researchers who track drug-use statistics from 16 metropolitan areas, reported that in San Diego County, opiate addiction (separate from heroin addiction) was the only category of addictive drugs for which treatment admissions had increased during the past five years. And the Drug Abuse Warning Network, a drug-monitoring group that tracks drug-related emergency-room visits, reported that in San Diego County, opiate abuse landed more people in the ER (460) in 2006 than heroin (371) cocaine (342) and marijuana (432).
Jails are another story. In a study commissioned by the Drug Policy Alliance that's not yet been made public, San Francisco attorney Jennifer Schwartz looked at what options are available to jail inmates in 16 California counties who are addicted to opiates or who are already enrolled in a methadone-treatment program at the time of their arrest.
For the latter group, San Diego County jail inmates must arrange for a family member to bring them their daily dose of methadone, which is then administered by a jail nurse. That arrangement is available to "short stay" inmates only, Schwartz said, though she was unable to find any jail official who could tell her what constituted a short stay.
Last year, new law made additional money available for counties to spend on Prop. 36-eligible offenders who were slipping through the cracks. Called the Offender Treatment Program, the money came with recommendations, among them that counties offer narcotic-replacement therapy to heroin addicts who were violating probation. But it's only a recommendation, said Lisa Fisher, an ADP spokesperson.
"One of the hallmarks of Prop. 36 is local control," she said. "We would not tell [counties], You have to do this,' but we can certainly give them what our research has found to help improve outcomes."
Schwartz said that an impetus for the Drug Policy Alliance study was to examine whether jails should be mandated to provide methadone or a similar narcotic replacement to opiate-addicted inmates-both to stabilize them and start them on a treatment path.
"Our concern is what is happening to these people withdrawing if they're not being constantly monitored," she said.
"My overall impression was [the jails] are basically doing next to nothing, and the state department is really trying to get them more and more involved, as are the private providers, but they just don't seem very interested."
Jim Dunford, medical director for the city of San Diego, said inmates in downtown's Central Jail who come in addicted to heroin are given medication to ease withdrawal, though methadone's not one of them. "We make sure their withdrawal symptoms are being adequately managed," he said.
Schwartz found only two county jail systems-Marin and Mendocino-that had medically assisted drug treatment programs for inmates.
According to the San Diego Association of Governments' Substance Abuse Monitoring Program, while roughly two-thirds of county arrestees tested positive for drugs in 2006, only about 6 percent tested positive for heroin-a number that's remained unchanged since 2004. But of that 6 percent, three-quarters said they preferred to inject heroin, as opposed to snorting or smoking it. The most recent CEWG report found, too, that more heroin addicts in San Diego County are opting to inject the drug-likely because it produces the fastest high. According to CEWG, 82 percent of heroin addicts who entered treatment in 2006 said they preferred to shoot the drug-a 10-percent increase from 2005. This put San Diego County fourth among large metropolitan areas when it comes to IV drug use among heroin addicts. Because of injection drug use's attendant health issues-like hepatitis C, HIV and other infections that are spread through the use of dirty needles-studies have put the cost-benefit ratio for treating IV-drug users higher than for other drug users-between $7 and $12 saved for every $1 spent. Jail is where Gretchen Burns Bergman's son, "Adam" (she requested that his real name not be used) learned how to shoot heroin. He had been smoking the drug and was convicted for drug possession when he was 19. With no access to syringes, inmates fashion makeshift shafts to inject drugs. It was from one of these shafts that Burns contracted hepatitis C.
After spending 11 years in and out of treatment programs and jail, Adam decided to give methadone a try. Bergman is the executive director of Parents for Addiction Treatment and Healing (PATH).
Bergman said she initially wasn't in favor of methadone treatment. Like many critics of medically assisted treatment, she saw it as simply replacing one drug with another. She knew her son was already using methadone to tide him over until he could buy more heroin.
"They say [addicts] have an epiphany somewhere along the line, and I think here he was in his early 30s knowing he had overdosed several times, knowing he'd been tossed aside by society behind bars, but also, as he's described to me, knowing that his family still loved him so it was sort of like: Maybe I could try to use this methadone the right way. And just see if I could do it," Bergman said.
Adam's been clean for five years and works as a drug-treatment counselor in a medically assisted treatment program.
He's applying to graduate school, Bergman said. He's done well enough on methadone that he gets a 30-day take-home supply rather than having to show up daily for his dose. Bergman says Adam is able to function perfectly well on methadone but has talked about tapering off the drug or trying a newer form of narcotic-replacement drugs called Suboxone.
"I think there's that terrible fear-your life has balanced and it's good-of Oh my god, I don't want to rock the boat' type of mentality. Some people may want to be on [methadone] for the rest of their lives-that feeling of I never want to slip; I never want to go back and lose everything I've worked so long to regain in my life."
Bergman said that at drug-treatment conferences and statewide meetings she attends, she hears complaints about San Diego County's unwillingness to not only implement a methadone program, but also to be more progressive when it comes to treatment options.
"It's conservative San Diego" Bergman said. "Our Board of Supervisors, we have to fight on every level, even in terms of things that have been proven to really save lives, like needle-exchange programs.
"Sometimes when I go to these conferences with other cities, I listen to what San Francisco's doing, and I'm going, You guys are so with it, so understanding.'"
A number of people CityBeat spoke to for this story pointed to the county Board of Supervisors as the reason why methadone isn't part of any county programs. A spokesperson for Greg Cox, the board's current chairperson, said the supervisors have never taken an official position on methadone (unlike needle exchange-a program where addicts can exchange dirty syringes for clean ones and get treatment referrals in the process. Supervisors passed a resolution against needle-exchange programs in 1997. The city of San Diego is the only city in the county that allows a needle-exchange program). The county used to fund methadone programs, but, like many other counties, cut funding in the late 1970s.
In a 2001 interview for a San Diego Magazine article on the rise in HIV infections in San Diego County, Supervisor Bill Horn, in response to questions about why the county doesn't fund methadone or needle-exchange programs, said his cousin died from a heroin overdose after a failed attempt at methadone treatment. Horn did not respond to requests for an interview.
Both Whitmyer and Peloquin have tried to meet with supervisors to see if they could change their minds.
"Dennis and myself have approached the county to say, Hey, why don't we have any of this treatment here?' Their response has been that the county Board of Supervisors disagrees with that treatment. Wonderful-let's talk to them. Let me educate them," Peloquin said.
"We have relationships with all the other counties within the state of California that [CRC is] in," Peloquin added. "We have the exclusive Prop. 36 and methadone treatment contracts in Riverside. We participate at some level in L.A. We're also participants in San Bernardino and Sacramento."
If the county's decision to not fund methadone treatment has been residents' loss, it's been CRC's gain. Where government isn't able to fill a need, the private sector picks up the slack. A 2005 study by the federal Substance Abuse and Mental Health Administration found that 54 percent of facilities that provide medically assisted drug treatment were run by private, for-profit entities while 35 percent were run by nonprofits and only 11 percent by federal, state or local governments.
Two years ago, CRC was purchased by Bain Capital (probably best known for its former CEO, Mitt Romney), and the infusion of cash has helped turn CRC into the largest drug-and-alcohol addiction treatment provider in the nation. Currently, CRC serves more clients than any other San Diego County drug-treatment provider.
Peloquin said it's not self-interest that's pushing him to advocate for medically assisted treatment. "If the Board of Supervisors say that they'll allow methadone treatment and CRC was not awarded the contract, I'm fine with that. As long as methadone treatment's being provided, that's fine."
Whitmyer, who ran drug-free treatment programs before moving over to CRC three-and-a-half years ago, sees it a little differently. He doesn't want to deal with county bureaucracy.
"What we want is acceptance of who we are and that we're here and they refer people to us. I want Prop. 36 money, by the way, but as far as county funding, it's too much to deal with them. But Prop. 36, we should be receiving funding for patients who qualify for Prop. 36."
Roughly 65 percent of clients pay for treatment out-of-pocket, Peloquin said, and the rest receive Drug Medi-Cal.
"if you're on meth, if you have an alcohol problem or a cocaine problem, the county will pay for your treatment, but if you have a heroin problem or an opiate problem, unless you're willing to go cold turkey in their social model programs, they won't pay," Whitmyer said.
CRC's largest facility is in Mission Valley, on Friars Road. From the building's south-facing windows you can see Nordstrom and the Fashion Valley Mall just across the street.
Sue Garrett is the program director at the Friars Road facility. Garrett's worked in the medically assisted treatment field for 20 years and has seen it evolve from so-called "juice bars," where clients would come in, take their dose of methadone and be hit up by a drug dealer on their way out.
"We've cleaned up a lot of that; we don't tolerate any drug activity on the property at all or you're out of here. We've come a long way," she said. "Back then, the services we provided, it was pretty basic. We didn't have patient-appreciation day, we didn't have [group therapy]."
Garrett and "Kathy" (she asked that her real name not be used) are sitting at a table in the conference room of the two-story building, which CRC bought from a previous methadone-provider five years ago and, according to Peloquin, spent half a million dollars to remodel. Kathy, an upbeat 36-year-old with shoulder-length blonde-brown hair, just had her second baby a few months ago. She's been on methadone for nine years, during which time she's had two kids (methadone has no adverse effects on a fetus), earned a master's degree and bought a house.
When Kathy was 15, a boyfriend introduced her to heroin. When her parents found out she was using, they put her in a two-week detox program. She started using again in college, "here and there," she says, until she got into a bad accident. "I started having pain-control problems, and [heroin] was a great solution."
She tried 21-day medically assisted detox programs but kept going back to using. A well-paying job and friends who were willing to buy heroin for her in exchange for a share of the purchase meant she had a steady supply of the drug. She knew how much she needed to function, she said: "As long as I had it, I was fine. The only time there's a problem is when you don't have it, because then you start going through withdrawals and you're in a really bad place."
One evening, she arrived home to find cops in her house. A friend, also a heroin addict, who was staying with Kathy, had an outstanding warrant. The police found Kathy's stash and arrested her, too. Her mom happened to be with her when it all went down.
"I saw there was a path-I could see it in my friends; I could see it in everybody around me-that that was not going to be my first encounter [with the police] if I continued on that road."
Methadone, she said, helped her get her life in order-because she didn't have to combat withdrawal, she was able to focus on what she needed to do to stay clean, like move out of San Diego and up to North County and cut ties with everyone she associated with as an addict.
"It's not just about taking away drugs; it's about taking away all the outside factors that influence why you're using," she said.
In addition to the CRC program, Kathy regularly attends AA meetings. It's there that she finds the same kind of treatment philosophy that governs programs like drug court: A person on methadone or any other narcotic-replacement drug isn't truly drug-free. The way some abstinence-only adherents see it, folks like Kathy are cheating. "There's a faction that says, You don't get to take tokens; you're not clean.' Well, no, you're taking Prozac; you're taking this, that and whatever. How come you're putting me off in a separate group? I'm abstaining just as much as anyone else."
Mark Parrino, AATOD's executive director, says medically assisted drug treatment needs to be thought about in the same way as any other illness for which medication is available.
"You have to strip away for a moment moral impediments and moral questions, and you have to say, We're treating in illness; this patient has a disease,'" Parrino said. "The disease is chronic in nature; it needs medication and ongoing treatment-the way you treat hypertension, the way you treat diabetes, which means that the patient stabilizes only as long as the patient takes medication."
One analog that proponents of medically assisted treatment point to is depression: Some people recover from depression after a year or so on medication; others might relapse and could require medication indefinitely. Likewise, it's not unusual to find folks who overcome depression simply through therapy, no prescription necessary.
"There's a thousand roads up the mountain" is how John Richardson puts it. Richardson is the vice president of Mental Health Systems-an addiction and mental-health treatment provider the county contracts with for services-and he's president of the county's Alcohol and Drug Service Providers Association.
Richardson said ADSPA is in the process of drafting a letter to the county saying that the association, which comprises 34 agency members, is taking an official position in support of medically assisted treatment.
"There's varying degrees of support" for medically assisted treatment among ADSPA members, Richardson said; "however, it's a consensus of ADSPA to acknowledge medically assisted treatment as a viable treatment methodology.
"We're not advocating for funding; we're not advocating for the board to do something different," he said.
Mental Health Systems follows the drug-free, social-model of treatment and Richardson said he's seen heroin addicts get clean and stay clean under that kind of program. According to the county, the success rate for heroin addicts in the programs it contracts with is 49.3 percent and for opiate addicts overall, 50.2 percent.
"It got a bad rap for many years because a lot of times the methadone clinics were considered juice bars," Richardson said, " and, quite frankly, they were. A lot of addicts abused the methadone system. However, a lot of people have gotten clean and sober and have recovered."
"I can supply numerous accounts as to why methadone maintenance is the best form of treatment for opiate addiction," Peloquin said. "Then it becomes a political issue and why that is I'm not sure.
"If I can get 15 or 20 minutes at the next county supervisors meeting to educate them on methadone treatment, then I will do that," Peloquin added, because at the end of the day, there's a lot of people in San Diego who aren't being treated for opiate abuse."