For Monica Cianci, a 38-year-old housewife in Cranston, R.I., hell began five years ago — and getting cancer was just the beginning.
Before her cancer surgery, she’d had “no trouble with drugs.” But afterward, she wound up addicted to prescription painkillers, opiate drugs like Vicodin and Percocet.
To combat that, doctors switched her to the painkiller methadone, a legal cousin of heroin from which addicts can be weaned slowly. But she got addicted to methadone, “a worse habit than I started with.” She tried to quit, but couldn’t: “I was crawling on the floor. . . . I was pouring sweat.”
Finally, she found the Nutmeg Intensive Rehabilitation Center in Tolland, Conn., which, like a growing number of medical centers and hospitals, offers opiate addicts a new — yet expensive and not well researched — way to get off drugs.
It’s called “rapid detox” and the idea is straightforward: Give patients general anesthesia plus a drug to induce withdrawal and other medications to combat withdrawal symptoms. The patient sleeps through the worst of it — pain, racing heart, cramps — and wakes up 6 hours later, “clean” and ready to try staying that way.
Treatment of opiate dependency is a dismal business — and an urgent one, mainly because of the growing popularity of a potent new form of heroin that doesn’t have to be injected; it’s sniffed.
The government believes 810,000 Americans are now addicted to heroin, but “the real number is undoubtedly higher,” says Dr. David R. Gastfriend, a psychiatrist who heads Massachusetts General Hospital’s addiction services.
Heroin is “the new party drug, and the reason is you can sniff it,” he says. In the early 1990s, the main consumers were the “fast-living crowd, the glamour media folks . . . people in the stock trading world who were looking for instant turn-ons.” Now, it’s in suburbia, inside public and private schools. “You don’t have to go into tough neighborhoods to get it anymore.”
Getting off heroin is, of course, harder than getting started, though there are many ways to try, says Dr. Herbert Kleber, a psychiatrist who heads the substance abuse divisions at Columbia University College of Physicians and Surgeons and the New York State Psychiatric Institute.
One approach, for instance, is to switch heroin addicts to methadone, then wean them off that. Another is to use medications like naloxone, which is injected to induce rapid withdrawal, and naltrexone, which is taken by mouth to block heroin and help addicts stay clean. Behavioral therapy, residential communities, and groups like Narcotics Anonymous can also help.
But it’s extremely tough going. At one year post-treatment, the relapse rate is about 75 percent. And many addicts never get past the first hurdle — the detoxification process itself.
Opiate drugs act by binding to mu receptors in the brain; with chronic use, the brain changes to adapt to the presence of opiates, says Dr. David Simon, an anesthesiologist who heads the Nutmeg center.
Then, if opiates are stopped, biochemical chaos ensues. In particular, part of the brain called the locus ceruleus goes into overdrive, pumping out the stress hormone noradrenalin. This triggers the pain, muscle spasms, and diarrhea that give withdrawal its nicknames — “cold turkey” for the goosebumps caused by muscle spasms around hair follicles, “kicking the habit” for involuntary leg movements.
One way to pry opiates off mu receptors is with naltrexone or naloxone, narcotic “antagonist” drugs that have 140 times more “affinity” for mu receptors than heroin, which means they push heroin off these receptors and keep it off.
But the abrupt withdrawal they trigger is virtually intolerable. To remedy that, in the late 1970s, Kleber and others began using a blood pressure drug, clonidine (Catapres) to ease these symptoms by blocking noradrenalin. Since then, Yale University researchers have shown they can detoxify two-thirds of addicts in a few days by using clonidine plus naltrexone.
For addicts terrified of withdrawal, however, that’s still not fast enough — hence the appeal of anesthesia-assisted detoxification.
In 1996, Bennett Oppenheim, a psychologist in Fort Lee, N.J., imported a rapid detox progam developed overseas by the Center for Investigation and Treatment of Addiction Inc., whose parent company is now in Beverly Hills, Calif.
So far, he has supervised the process in 700 patients, including some at Pascack Valley Hospital in Westwood, N.J. He estimates that six months after rapid detox, for which he charges $6,800, 55 percent of addicts are still clean.
One of the specialists he recruited is Dr. Clifford Gevirtz, an anesthesiologist at Metropolitan Hospital Center in New York. Initially skeptical, Gevirtz, who has “detoxed” 184 patients and charges $4,500 for it, says he is now “a true believer” in rapid detox: “It’s the compassionate approach.”
Dr. David Simon of Nutmeg, who charges $3,400, claims a higher success rate among the 350 patients he has detoxed so far. Based on the first 162, he says, 75 percent are clean, though that’s at three months after detox.
Simon’s patients are treated in a free-standing center, not a hospital, and they do not stay overnight, though many stay nearby. That rankles Oppenheim: “While this is a relatively safe procedure, it requires ICU-level monitoring and an overnight hospital stay.”
Indeed, even in good hands, complications can arise.
Kleber knows of at least four deaths — two in New Jersey and two in Great Britain — though it’s impossible to calculate a mortality rate because no one knows how many people have had the procedure. Still, he says, “the body is stressed sufficiently that you may get cardiac arrhythmias” during or for several days afterward.
And sometimes — as at St. Elizabeth’s Medical Center in Boston — the cause of death is never known. Dr. Carl Gold, a St. Elizabeth’s anesthesiologist, has rapidly detoxed 40 patients, one of whom died three days later. The family refused an autopsy, so the cause of death is unclear.
Gold works with the Uniqual Network, a Framingham company that helps medical centers set up detox programs. He says 25 to 30 percent of his patients are clean a year later. Rapid detox “is not the magic bullet,” he says, but it can get patients clean, so they can try to stay that way.
In most cases, insurers don’t pay for rapid detox. But it’s such a lucrative procedure that entrepreneurs now offering it are fighting over patients and, in the case of Nutmeg and Uniqual, legally sparring with each other.
But it’s the unanswered scientific questions that are the most troubling. An unofficial review of rapid detox in 1996 by the National Institute on Drug Abuse concluded it has not been shown to be any better than other treatments in reducing relapse.
Until there are data from a controlled trial — which Kleber hopes to begin soon — rapid detox “should not be a clinical procedure,” he says. “It should be a research procedure.”
At Mass General, Gastfriend, who has used rapid detox for seven patients, worries about the potential for exploitation because “patients are so desperate.”
But at least some of those who’ve been detoxed at Nutmeg, MGH or Pascack Valley Hospital are glad they took the chance.
“Joseph,” a 39-year-old New Yorker who had a $300-a-day habit, went through rapid detox with Oppenheim. Several days later, he said he felt tired but was optimistic he could stay well. A 49-year-old Rhode Island man who had rapid detox at MGH, said the process made him feel he was “dying — I was very, very sick.”
Even so, he says, rapid detox “was the best thing I ever did” because trying to kick his habit gradually simply didn’t work. As for Monica Cianci, her gratitude toward Nutmeg knows no bounds. The staff was “absolutely wonderful,” she says. “I am absolutely clean now. I will stay clean for rest of life. . . I know I am going to be a success story.”
SIDEBAR:
New medications may reduce opiate cravings
While rapid detox has drawn the most headlines, scientists are working on other ways to help addicts get and stay clean.
Among the most exciting is a pair of related drugs that dissolve under the tongue, expected to be called Subutex and Suboxone, under joint development by the National Institute on Drug Abuse and Reckitt & Colman Pharmaceuticals, Inc. of Richmond, Va.
A close cousin of these drugs, Buprenex, is already on the market for pain control, but must be taken by injection. All three drugs contain a chemical called buprenorphine.
The new medications, expected to be reviewed later this year by the US Food and Drug Administration, will be “very significant” additions to the drugs now used to treat opiate dependency, chiefly methadone and another drug known as LAAM, says Alan I. Leshner, a psychologist who heads the drug abuse institute.
Methadone is a synthetic opiate that blocks heroin’s effects for 24 hours. It is provided to addicts only in clinics and can be used, in decreasing doses, to wean them from heroin. LAAM (l-alpha acetylmethadol) is another synthetic opiate that blocks the effects of heroin, for up to 72 hours.
In addition, naloxone, a drug given intravenously, and naltrexone, a pill, can be taken to block the effects of heroin.
NIDA has funded studies that show the two new drugs are safe and effective. Like heroin and methadone, buprenorphine latches onto mu receptors in the brain. But while heroin and methadone are full “agonists,” which means the more one takes, the bigger the effect, buprenorphine is a partial agonist, which means it has a ceiling — after a certain dose taking more has no effect.
In addition, Suboxone has an extra feature. To prevent abuse, it is hitched to naloxone, which would trigger unpleasant withdrawal symptoms if an addict were to grind it up and inject it. (Naloxone can’t be absorbed under the tongue, so it would probably not trigger withdrawal symptoms if taken as directed.)
Ultimately, Suboxone may even be dispensed by prescription for at-home use, which would be easier for recovering addicts than having to go to a methadone clinic every day.